What is the management plan for a cirrhotic patient with large volume ascites and delayed paracentesis?

Admission Checklist for Cirrhotic Patient with Large Volume Ascites and Delayed Paracentesis

Perform diagnostic paracentesis immediately upon admission, as this is mandatory for all cirrhotic patients with ascites on hospital admission, regardless of whether therapeutic paracentesis is delayed. 1

Immediate Diagnostic Workup

Paracentesis Requirements

• Obtain informed consent for diagnostic paracentesis before proceeding 1, 2
• Perform diagnostic tap immediately even if therapeutic paracentesis is delayed—this is non-negotiable for hospitalized cirrhotic patients with ascites 1, 3
• Inoculate ascitic fluid into blood culture bottles at the bedside to maximize detection of spontaneous bacterial peritonitis (SBP) 1
• Send ascitic fluid for: neutrophil count, culture, total protein, and serum-ascites albumin gradient (SAAG) 1, 3, 2
• Add ascitic amylase only if pancreatic disease is clinically suspected 1, 2

Laboratory Assessment

• Serum electrolytes (sodium, potassium, creatinine) to guide diuretic management and detect complications 1
• Complete blood count to assess for peripheral leucocytosis suggesting infection 1
• Liver function tests and coagulation profile 3
• Serum albumin to calculate SAAG 1, 3

Immediate Management Priorities

Infection Surveillance

• Start empiric antibiotics immediately if ascitic fluid neutrophil count ≥250 cells/mm³, even before culture results 1
• Use third-generation cephalosporins (cefotaxime is most extensively studied) as first-line therapy for suspected SBP 1
• Administer albumin 1.5 g/kg within 6 hours followed by 1.0 g/kg on day 3 if SBP is present with signs of renal impairment (creatinine >88 μmol/L or rising) 1, 2

Dietary Restrictions

• Implement no-added-salt diet immediately: restrict to 90 mmol salt/day (5.2 g salt/day) 1, 3
• Avoid precooked meals which are typically high in sodium 3
• Do NOT restrict fluids unless serum sodium <125 mmol/L 1, 3

Diuretic Management Based on Electrolytes

For serum sodium 126-135 mmol/L with normal creatinine:

• Continue existing diuretics if already on them 1
• Monitor electrolytes closely 1
• Do NOT restrict water 1

For serum sodium 121-125 mmol/L with normal creatinine:

• Stop diuretics or adopt cautious approach (international opinion varies, but stopping is safer) 1

For serum sodium 121-125 mmol/L with elevated creatinine (>150 μmol/L or >120 μmol/L and rising):

• Stop diuretics immediately 1
• Give volume expansion with colloid (haemaccel, gelofusine, voluven) or saline 1

For serum sodium <120 mmol/L:

• Stop diuretics immediately 1
• Provide volume expansion with colloid or saline 1
• Avoid increasing sodium by >12 mmol/L per 24 hours to prevent osmotic demyelination 1
• Restrict fluids to 1-1.5 L/day only at this severe level 3

Planning for Therapeutic Paracentesis

Pre-Procedure Preparation

• Ensure coagulation parameters are acceptable (though routine correction is not typically required) 3
• Plan for single-session complete drainage when therapeutic paracentesis is performed 4, 2
• Arrange albumin availability: 8 g albumin per liter of ascites removed for volumes >5 liters 1, 4, 2
• For volumes <5 liters: synthetic plasma expanders (150-200 ml gelofusine or haemaccel) are acceptable alternatives to albumin 1

Post-Paracentesis Planning

• Initiate or optimize diuretics after paracentesis to prevent reaccumulation 4, 2
• Start with spironolactone 100 mg daily for first presentation of moderate ascites 3, 2, 5
• Use combination therapy (spironolactone 100 mg + furosemide 40 mg) for recurrent or severe ascites 3, 2
• Plan for drain removal within 24 hours of paracentesis to reduce risk of drain-related bacterial peritonitis and acute kidney injury 6

Critical Safety Considerations

Medications to Avoid

• Strictly avoid NSAIDs as they reduce diuretic efficacy and can precipitate renal failure 4
• Hold diuretics if patient develops hyponatremia or rising creatinine as detailed above 1

Monitoring During Admission

• Daily weights to assess fluid status 3, 4
• Serial electrolytes every 2-3 days while on diuretics 1
• Watch for hepatic encephalopathy, which may indicate SBP or excessive diuresis 1, 7
• Monitor for renal impairment (rising creatinine, oliguria) 1, 7

Transplant Evaluation

Initiate liver transplant evaluation immediately as development of ascites indicates poor prognosis (85% one-year survival, 56% five-year survival without transplant) 1, 3, 8, 9

Common Pitfalls to Avoid

• Do NOT delay diagnostic paracentesis even if therapeutic paracentesis is postponed—missing SBP can be fatal 1
• Do NOT restrict fluids routinely—only for severe hyponatremia <125 mmol/L 1, 3
• Do NOT perform therapeutic paracentesis without arranging post-procedure albumin for large volumes 1, 4, 2
• Do NOT continue diuretics in patients with hyponatremia <125 mmol/L and rising creatinine 1
• Do NOT leave paracentesis drains in place >24 hours due to increased infection and AKI risk 6