From the Guidelines
Paracentesis should be performed during hepatic encephalopathy with caution, considering the risk of postparacentesis circulatory dysfunction (PPCD), and albumin infusion is recommended to mitigate this risk, especially when removing more than 5 L of ascites. When performing paracentesis in patients with hepatic encephalopathy, it is crucial to weigh the benefits of the procedure against the potential risks, including PPCD, which can exacerbate encephalopathy, renal impairment, and even death 1. The American Association for the Study of Liver Diseases recommends albumin infusion at the time of large-volume paracentesis (LVP) to prevent PPCD, with a suggested dose of 6-8 g of albumin per liter of ascites removed 1. Key considerations for paracentesis in hepatic encephalopathy include:
- The volume of ascites to be removed, with larger volumes (>5 L) requiring albumin infusion to prevent PPCD
- The patient's overall clinical status, including the severity of encephalopathy and presence of other complications such as renal impairment or hyponatremia
- The potential benefits of paracentesis in diagnosing and managing conditions such as spontaneous bacterial peritonitis (SBP), which can precipitate or worsen encephalopathy. In patients with hepatic encephalopathy undergoing paracentesis, albumin infusion is particularly important to prevent PPCD and its associated complications, and the procedure should be performed by experienced healthcare professionals with careful monitoring of the patient's hemodynamic status 1.
From the Research
Paracentesis and Hepatic Encephalopathy
- Paracentesis is a procedure used to treat ascites, a common complication of liver cirrhosis, which can be associated with hepatic encephalopathy 2, 3.
- The use of human albumin in patients with cirrhotic ascites undergoing paracentesis has been shown to reduce the odds of paracentesis-induced circulatory dysfunction (PICD) and hyponatremia, but does not reduce the overall mortality, readmission rate, recurrence of ascites, or hepatic encephalopathy 2.
- Early paracentesis in high-risk hospitalized patients with ascites and hepatic encephalopathy has been associated with reduced inpatient mortality, SBP-related mortality, and 30-day readmission 3.
- The management of hepatic encephalopathy in the hospital involves evaluating patients for secondary triggers, initiating treatment with nonabsorbable disaccharides, and considering other therapies such as rifaximin and zinc 4.
- Hepatic encephalopathy is a prognostically relevant neuropsychiatric syndrome that occurs in the course of acute or chronic liver disease, and its severity classification and diagnostic approaches are still a matter of debate 5.
Paracentesis in Patients with Hepatic Encephalopathy
- A history of hepatic encephalopathy is not a contraindication to transjugular intrahepatic portosystemic shunt (TIPS) placement for refractory ascites, and pre-TIPS HE does not predispose patients to increased all-cause mortality or risk of experiencing HE within 60 days 6.
- Predictors of post-TIPS clinical outcomes for patients with and without pre-TIPS HE include total bilirubin, blood urea nitrogen, age, creatinine, and Child-Pugh score 6.