What are the indications, contraindications, and guidelines for fluid withdrawal during a paracentesis procedure?

Paracentesis: Indications, Contraindications, and Fluid Withdrawal Guidelines

Indications for Paracentesis

Diagnostic paracentesis should be performed in all patients with new-onset Grade 2 or 3 ascites, all hospitalized patients with worsening ascites, and any cirrhotic patient with complications including fever, abdominal pain, gastrointestinal bleeding, hepatic encephalopathy, hypotension, or renal insufficiency. 1

• Therapeutic paracentesis is first-line treatment for patients with large or refractory ascites causing symptomatic relief 1
• Diagnostic tap requires only 10-20 mL of fluid for analysis 1
• Large-volume paracentesis (LVP) is indicated when >5 liters need removal for symptom relief 1

Absolute and Relative Contraindications

The only absolute contraindication is clinically evident hyperfibrinolysis or disseminated intravascular coagulation. 1

Absolute Contraindications:

• Clinically evident hyperfibrinolysis (documented by shortened euglobulin clot lysis time <120 minutes) 1
• Disseminated intravascular coagulation 1

Relative Contraindications (proceed with caution):

• Pregnancy 1
• Severe intestinal distension 1
• Extensive abdominal surgery history 1
• Severe liver dysfunction 1
• Severe renal dysfunction 1

Critical Point About Coagulopathy:

Routine prophylactic transfusion of fresh frozen plasma or platelets before paracentesis is NOT recommended, even with severe coagulopathy. 1 Studies document safe paracentesis with INR as high as 8.7 and platelet counts as low as 19,000 cells/mm³ without prophylactic correction 1. Bleeding complications occur in <1/1000 procedures 1.

Procedure Technique

Site Selection:

The left lower quadrant is the preferred location, 2 finger breadths (3 cm) cephalad and 2 finger breadths medial to the anterior superior iliac spine. 1

• This site has thinner abdominal wall and greater ascites depth than midline 1
• Insert at least 8 cm from midline and 5 cm above symphysis pubis to avoid inferior epigastric arteries 1
• Avoid visible collateral vessels 1
• Use ultrasound guidance when available to reduce adverse events 1

Technique Details:

• Use "Z-track" technique: penetrate skin perpendicularly, advance obliquely in subcutaneous tissue, then puncture peritoneum perpendicular to abdominal wall 1
• Use cannula with multiple side perforations to prevent bowel wall blockage 1
• Perform under strict sterile conditions 1

Maximum Fluid Withdrawal Volume

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

• Complete drainage in one session is more effective than serial smaller procedures 1
• No upper limit is specified in current guidelines when appropriate albumin replacement is given 1
• Historical concerns about circulatory collapse from rapid large-volume removal have been disproven 2
• Typical drainage rate is 2-9 liters per hour 2
• Do not leave drain in overnight 1

Post-Procedure Care:

• Patient should lie on opposite side for 2 hours if ascitic fluid leakage occurs 1
• Consider purse-string suture around drainage site to minimize leakage 1

Albumin Replacement Protocol

For paracentesis >5 liters, albumin replacement is mandatory at 8 g per liter of ascites removed to prevent post-paracentesis circulatory dysfunction (PICD). 1, 3

Dosing Algorithm:

• <5 liters removed: No albumin required unless patient has acute-on-chronic liver failure 1, 3
• >5 liters removed: 8 g albumin per liter removed (e.g., 100 mL of 20% albumin per 3 liters) 1, 3
• Example: 8 liters removed = 64 g albumin (approximately 320 mL of 20% albumin) 3

Administration:

• Infuse albumin after paracentesis is completed, not during 1, 3
• Use 20% or 25% albumin solution 1
• Infuse slowly to prevent cardiac overload in patients with cardiomyopathy 3

Evidence for Albumin Superiority:

Albumin reduces PICD by 61% (OR=0.39), mortality by 36% (OR=0.64), and hyponatremia by 42% (OR=0.58) compared to alternative plasma expanders. 3

• PICD occurred in 18.5% with albumin vs 34.4% with dextran-70 vs 37.8% with poligelina 3
• Alternative expanders (dextran-70, poligelina, saline) are inferior 3

Complications and Risk Management

Hemorrhage Risk:

• Severe hemorrhage occurs in 0.2-2.7% of procedures 1
• Death rate is 0.02% (1 in 5,000 procedures) 1
• Most bleeding occurs within 6-24 hours but can be delayed up to 1 week 1
• Bleeding sources: superficial epigastric vein, inferior epigastric artery, mesenteric varices, paraumbilical vein 1

Management of Bleeding:

• Most cases respond to medical treatment: fluid resuscitation, transfusion, coagulation correction 1
• Consider transcatheter coil embolization or laparoscopy with vessel ligation if hemodynamically unstable 1
• TIPS or liver transplantation for severe bleeding 1

Other Complications:

• Ascitic fluid leak: 0-2.35% 1
• Bowel perforation: 0.83% 1
• Infection: rare 1

Critical Pitfalls to Avoid

1. Do NOT withhold paracentesis due to elevated INR or thrombocytopenia - routine correction is not indicated 1
2. Do NOT artificially slow drainage rate - rapid drainage over 1-4 hours is safe and evidence-based 2
3. Do NOT omit albumin for >5 liter paracentesis - this prevents life-threatening PICD 3
4. Do NOT confuse with spontaneous bacterial peritonitis albumin dosing - SBP requires 1.5 g/kg day 1 and 1 g/kg day 3, not per-liter dosing 3
5. Do NOT perform repeated small-volume paracenteses - single complete drainage is safer and more effective 1, 2