What is large volume paracentesis?

What is Large Volume Paracentesis

Large volume paracentesis (LVP) is the removal of more than 5 liters of ascitic fluid from the peritoneal cavity in a single session, performed to rapidly relieve symptoms of tense ascites in patients with cirrhosis. 1, 2

Definition and Volume Thresholds

• LVP is arbitrarily defined as removal of >5 liters of ascitic fluid, though some sources define it as >4 liters 1, 3
• There is no absolute upper limit for volume removal in a single session, provided appropriate albumin replacement is administered 2, 4
• Complete drainage to dryness in a single session is the recommended approach, rather than leaving residual fluid 1, 5, 4

Clinical Purpose and Indications

• LVP rapidly relieves tense ascites within minutes to hours, compared to days or weeks required for diuretic therapy 1
• Primary indication is symptomatic relief of tense ascites causing severe abdominal distention, pain, and dyspnea 6
• LVP is first-line treatment for refractory ascites when diuretics become ineffective or cause intolerable side effects 1, 2

Procedure Technique

• All ascitic fluid should be drained to dryness as rapidly as possible over 1-4 hours in a single session 1, 2, 5
• The typical drainage rate is approximately 2-9 liters per hour, with mean procedure duration of 97±24 minutes 2
• Needle insertion site should be in the left lower quadrant (preferred), at least 8 cm from midline and 5 cm above symphysis pubis, where the abdominal wall is thinner and ascites depth is greatest 1, 2
• Use the Z-track technique with perpendicular skin penetration and oblique subcutaneous advancement to prevent post-procedure leakage 2, 4
• Ultrasound guidance should be used when available to reduce adverse events 1, 2, 4

Critical Albumin Replacement Protocol

For volumes >5 liters: Mandatory albumin replacement at 8 grams per liter of ascites removed (e.g., 100 mL of 20% albumin per 3 liters removed) 1, 2, 4

For volumes <5 liters: Albumin replacement is not necessary unless the patient has acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury 2, 5

• Albumin should be infused after paracentesis is completed, not during the procedure 2
• Albumin prevents post-paracentesis circulatory dysfunction (PICD), reducing odds of PICD by 61%, hyponatremia by 42%, and mortality by 36% compared to alternative volume expanders 2

Safety Profile and Complications

• Hemorrhagic complications occur in 0-2.7% of cases, with abdominal wall hematomas being most common (52% of bleeding complications), followed by hemoperitoneum (41%) 1, 7
• Overall complication rate is approximately 1%, despite 71% of patients having abnormal prothrombin time 1
• Serious complications (hemoperitoneum, bowel perforation) occur in approximately 1/1000 paracenteses 1
• Routine prophylactic transfusion of fresh frozen plasma or platelets is not recommended, even with INR as high as 8.7 or platelets as low as 19×10³/μL 1, 2

Common Pitfalls to Avoid

• Do not artificially slow drainage rate out of concern for hemodynamic instability—historical concerns about circulatory collapse from rapid removal have been disproven, as removing >10 liters over 2-4 hours causes only minimal blood pressure changes (<8 mmHg decrease) 2
• Do not withhold paracentesis due to coagulopathy or thrombocytopenia—routine correction of INR or platelet count is not supported by evidence 1, 2
• Never remove ascites without albumin replacement when volume exceeds 5 liters—this causes significant complications including renal impairment, severe hyponatremia, and marked activation of the renin-angiotensin-aldosterone system 2, 4, 8
• Do not leave the drain in overnight—remove immediately after complete drainage is achieved 1, 5

Post-Procedure Management

• After paracentesis, the patient should lie on the opposite side for 2 hours if there is leakage of remaining ascitic fluid 1, 5
• A purse-string suture may be placed around the drainage site to minimize leakage risk 1, 5
• LVP does not correct the underlying sodium retention problem—patients require sodium restriction and diuretics to prevent reaccumulation 1