Post-Paracentesis Management After 13.5L Removal
Administer 108 grams of intravenous albumin (20% or 25% solution) immediately post-procedure, calculated at 8 g per liter of ascites removed, to prevent post-paracentesis circulatory dysfunction and reduce mortality. 1
Immediate Post-Procedure Albumin Administration
The albumin infusion is mandatory and non-negotiable for this volume removal. 1
- Infuse albumin after paracentesis completion, not during the procedure 1
- Use 20% or 25% albumin solution for the 108-gram total dose 1
- This translates to approximately 540 mL of 20% albumin solution 2
- Albumin prevents post-paracentesis circulatory dysfunction (PICD), which occurs in up to 80% of patients without volume expansion 1
- Without albumin, expect significantly higher rates of renal impairment, hyponatremia, and activation of renin-angiotensin-aldosterone system 1, 3
Hemodynamic Monitoring Timeline
Monitor blood pressure and clinical status closely for the first 6 hours post-procedure. 1
- Hemodynamic changes are maximal at 3 hours post-paracentesis 1
- Pulmonary capillary wedge pressure decreases at 6 hours and continues falling without colloid replacement 1
- Average blood pressure decrease is <8 mmHg, though severe hypotension can occur in advanced liver disease 1
- Post-paracentesis circulatory dysfunction severity correlates inversely with patient survival 1
Diuretic Management
Restart or initiate diuretic therapy within 1-2 days post-paracentesis. 1, 4
- Without diuretics, ascites recurs in 93% of patients 1, 4
- With spironolactone, recurrence drops to only 18% 1, 4
- Reintroducing diuretics within 1-2 days does not increase risk of post-paracentesis circulatory dysfunction 1
- Standard dosing: spironolactone 100-400 mg/day plus furosemide 40-160 mg/day in 100:40 ratio 1
Laboratory Monitoring
Check renal function, electrolytes, and sodium on days 3-6 post-procedure. 1, 3
- Monitor for hyponatremia (serum sodium <120 mmol/L) 1, 3
- Check serum creatinine for renal impairment (>2.0 mg/dL indicates diuretic complication) 1
- Monitor serum potassium (>6.0 mmol/L indicates diuretic toxicity) 1
- Plasma renin activity >25.15 ng/mL at day 3 predicts PICD development with 71% sensitivity 5
Clinical Surveillance for Complications
No routine repeat paracentesis or imaging is needed unless specific complications develop. 4
- Repeat paracentesis only if fever, abdominal pain, or signs of infection develop 4
- Rescan for leukocytosis, encephalopathy, renal failure, or acidosis 4
- Monitor for hemorrhagic complications: abdominal wall hematomas (52% of bleeding complications) or hemoperitoneum (41%) 6
- If hemorrhage occurs, interventional radiology with transcatheter coiling/embolization is superior to surgery (lower 30-day mortality) 6
Critical Pitfalls to Avoid
Failure to administer albumin is the single most dangerous error. 1, 3
- Without albumin after this volume removal, expect renal impairment in 21% of patients versus 2% with albumin 3
- Hyponatremia develops in 17% without albumin versus 8% with albumin 1
- Mortality increases by 36% without albumin replacement 2
- Never use synthetic plasma expanders (dextran-70, polygeline) as substitutes—they cause PICD in 34-38% versus 18.5% with albumin 1
Failure to restart diuretics leads to rapid reaccumulation. 1, 4
- This is the second most common management error 4
- Ascites will recur in 93% without diuretic therapy 1
Evidence Quality Note
The albumin dosing recommendation (8 g/L for >5L removal) comes from high-quality British Society of Gastroenterology guidelines 1 and is supported by multiple randomized trials showing reduced renal impairment, hyponatremia, and mortality 3. While one small study suggested albumin might be omitted for <5L removal, expert consensus strongly recommends against extrapolating this to larger volumes 1. For 13.5L removal, albumin is absolutely mandatory based on all available evidence.