What are the guidelines for managing paracentesis?

Guidelines for Managing Paracentesis

Paracentesis should be performed with ultrasound guidance whenever possible to reduce the risk of serious complications, improve success rates, and ensure sufficient fluid is present for drainage. 1

Diagnostic Paracentesis

• A diagnostic paracentesis should be performed in all cirrhotic patients with ascites on hospital admission and in those who develop signs of peritoneal infection, encephalopathy, or renal impairment 2

• Initial ascitic fluid analysis should include:

  • Serum ascites-albumin gradient (SAAG) to determine the cause of ascites 2
  • Neutrophil count and culture to rule out infection (>250 cells/mm³ indicates spontaneous bacterial peritonitis) 2
  • Ascitic amylase should be measured when pancreatic disease is suspected 2

• Informed consent should be obtained from patients prior to performing paracentesis 2

Therapeutic (Large Volume) Paracentesis

Procedure Technique

• Ultrasound guidance should be used to:

  • Assess volume and location of fluid 1
  • Identify a safe needle insertion site 1
  • Evaluate for and avoid blood vessels using color flow Doppler 1
  • Mark the insertion site immediately before the procedure 1

• The left lower quadrant is preferred for paracentesis as the abdominal wall is thinner and depth of ascites greater in this location 2

• Point of puncture should be at least 8 cm from the midline and 5 cm above the symphysis to avoid injury to the inferior epigastric artery 2

• All ascitic fluid should be drained to dryness in a single session as rapidly as possible over 1-4 hours 2

• After paracentesis, the patient should lie on the opposite side for 2 hours if there is leakage, and/or a purse-string suture inserted around the drainage site 2

Coagulation Parameters

• Routine measurement of prothrombin time and platelet count before paracentesis and infusion of blood products are not recommended 2

Albumin Administration

• For paracentesis >5 liters:

  • Albumin (20% or 25% solution) should be infused after paracentesis is completed at a dose of 8 g albumin/L of ascites removed 2, 3
  • This prevents post-paracentesis circulatory dysfunction which can lead to renal impairment and electrolyte disturbances 3

• For paracentesis <5 liters:

  • Albumin replacement is generally not required 2
  • However, albumin (8 g/L) can be considered in high-risk patients with acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury 2, 3

• For patients with spontaneous bacterial peritonitis (SBP) and increased or rising serum creatinine:

  • Infuse 1.5 g albumin/kg within 6 hours of diagnosis, followed by 1 g/kg on day 3 2

Management of Ascites

Dietary Recommendations

• Patients with cirrhosis and ascites should have a moderately salt restricted diet with daily salt intake of no more than 5-6.5 g (87-113 mmol sodium) 2
• Nutritional counseling on sodium content in the diet should be provided 2

Diuretic Therapy

• First presentation of moderate ascites:

  • Spironolactone monotherapy (starting dose 100 mg, increased to 400 mg) 2

• Recurrent severe ascites or when faster diuresis is needed:

  • Combination therapy with spironolactone (starting dose 100 mg, increased to 400 mg) and furosemide (starting dose 40 mg, increased to 160 mg) 2

• Monitor for adverse events, as almost half of patients require diuretic discontinuation or dose reduction 2

Management of Hyponatremia

• Hypovolemic hyponatremia during diuretic therapy:

  • Discontinue diuretics and expand plasma volume with normal saline 2

• Fluid restriction (1-1.5 L/day) should be reserved for clinically hypervolemic patients with severe hyponatremia (serum sodium <125 mmol/L) 2

• Hypertonic sodium chloride (3%) administration should be reserved for severely symptomatic patients with acute hyponatremia 2

Refractory Ascites Management

• Transjugular intrahepatic portosystemic shunt (TIPSS) should be considered in patients with refractory ascites 2

• Caution is required if considering TIPSS in patients with:

  • Age >70 years
  • Serum bilirubin >50 μmol/L
  • Platelet count <75×10⁹/L
  • MELD score ≥18
  • Current hepatic encephalopathy
  • Active infection or hepatorenal syndrome 2

• Midodrine may be considered in refractory ascites on a case-by-case basis 2

Special Considerations

• Home-based paracentesis can be considered for hospice patients to provide symptomatic relief and improve quality of life 4

• For patients with hepatic hydrothorax, TIPSS should be considered after discussion with the multidisciplinary team 2

• Development of refractory ascites is of prognostic significance and should prompt consideration for liver transplantation 2