Guidelines for Paracentesis in Patients with Significant Ascites
Diagnostic paracentesis is strongly recommended for all patients with new-onset ascites or cirrhotic patients with ascites on hospital admission to establish diagnosis and rule out spontaneous bacterial peritonitis (SBP). 1, 2
Diagnostic Paracentesis Indications
- A diagnostic paracentesis should be performed in all patients with new-onset ascites to determine the cause 1
- All cirrhotic patients with ascites should undergo paracentesis on hospital admission 1
- Paracentesis should be performed in patients with signs of peritoneal infection, encephalopathy, renal impairment, or peripheral leukocytosis without a precipitating factor 1
- Patients with GI bleeding, shock, fever, systemic inflammation, gastrointestinal symptoms, or worsening liver/renal function should undergo diagnostic paracentesis 1
Diagnostic Paracentesis Procedure
- Informed consent should be obtained from patients prior to performing paracentesis 1, 2
- The left lower quadrant is the preferred site for paracentesis (at least 8 cm from midline and 5 cm above symphysis) 2
- Initial ascitic fluid analysis should include:
- Ascitic fluid should be inoculated into blood culture bottles at the bedside 1
- Additional tests like cytology, BNP, and adenosine deaminase should be considered based on pre-test probability of specific diagnoses 1
Therapeutic Paracentesis
- Therapeutic paracentesis is the first-line treatment for patients with large or refractory ascites 1, 2
- All ascitic fluid should be drained to dryness in a single session as rapidly as possible over 1-4 hours 2
- Volume expansion should be given once paracentesis is complete 1
- For paracentesis <5 liters, plasma expansion with a synthetic plasma expander (150-200 ml of gelofusine or haemaccel) is sufficient 1
- For large volume paracentesis (>5 liters), albumin should be administered at a dose of 8 g albumin/L of ascites removed 1, 2
- After paracentesis, the patient should lie on the opposite side for 2 hours if there is leakage, and/or a purse-string suture can be inserted around the drainage site 2
Management of SBP
- Ascitic neutrophil count >250/mm³ is the gold standard for diagnosis of SBP 1
- Immediate empirical antibiotic therapy should be started when SBP is suspected 1
- Third-generation cephalosporins like cefotaxime have been extensively studied for SBP treatment 1
- Patients with SBP and signs of developing renal impairment should receive albumin at 1.5 g/kg in the first six hours followed by 1 g/kg on day 3 1, 2
- A second diagnostic paracentesis at 48 hours should be considered in patients with inadequate response or suspected secondary bacterial peritonitis 1
Prophylaxis for SBP
- Patients who have recovered from an episode of SBP should receive prophylaxis with norfloxacin (400 mg daily), ciprofloxacin (500 mg daily), or co-trimoxazole 1
- Patients with GI bleeding and underlying ascites due to cirrhosis should receive prophylactic antibiotic treatment 1
Management of Refractory Ascites
- Transjugular intrahepatic portosystemic shunt (TIPS) should be considered for patients with refractory ascites requiring frequent therapeutic paracentesis 1, 2
- Development of refractory ascites should prompt consideration for liver transplantation 1, 2
Clinical Benefits of Paracentesis
- Paracentesis improves patient comfort and respiratory function by increasing functional residual capacity and total lung capacity 3
- Compared to diuretic therapy alone, paracentesis with albumin is associated with fewer complications (hepatic encephalopathy, renal impairment, electrolyte disturbances) and shorter hospital stays 4
- Intravenous albumin administration with large-volume paracentesis helps avoid renal and electrolyte complications and prevents activation of endogenous vasoactive systems 5