Management of Paracentesis in Patients with Significant Ascites
Therapeutic paracentesis is the first-line treatment for patients with large or tense ascites, and should be performed to complete dryness in a single session, followed by albumin replacement at 8 g per liter removed for volumes >5 liters. 1
Indications for Paracentesis
Diagnostic paracentesis must be performed in all cirrhotic patients with ascites on hospital admission and whenever patients develop signs of infection (fever, abdominal pain, tenderness), encephalopathy, renal impairment, or peripheral leukocytosis without clear precipitating factors. 1, 2
Obtain informed consent before performing the procedure, as this is a strong recommendation across all major guidelines. 3, 2
Pre-Procedure Considerations
Do not routinely check coagulation studies or transfuse blood products prophylactically before paracentesis. 3 Paracentesis can be safely performed even with significant coagulopathy, with bleeding complications occurring in less than 1 in 1,000 procedures. 3 The only absolute contraindications are clinically evident hyperfibrinolysis and disseminated intravascular coagulation. 3
Select the left lower quadrant as the preferred site, 2 finger breadths cephalad and 2 finger breadths medial to the anterior superior iliac spine, ensuring the puncture point is at least 8 cm from the midline and 5 cm above the symphysis to avoid the inferior epigastric artery. 3, 2 Consider ultrasound guidance when available, particularly in patients with obesity, pregnancy, severe intestinal distension, or extensive prior abdominal surgery. 3
Procedure Technique
For diagnostic paracentesis, withdraw 10-20 mL of ascitic fluid using a syringe. 3 Immediately inoculate ascitic fluid into two blood culture bottles at the bedside to maximize detection of spontaneous bacterial peritonitis (SBP). 1, 3
For therapeutic paracentesis, drain all ascitic fluid to dryness in a single session as rapidly as possible over 1-4 hours. 2 This approach is more effective than attempting multiple smaller-volume procedures. After completion, have the patient lie on the opposite side for 2 hours if leakage occurs, or insert a purse-string suture around the drainage site. 2
Essential Ascitic Fluid Analysis
Send fluid for:
- Serum ascites-albumin gradient (SAAG) in preference to ascitic protein to determine portal hypertension (SAAG >1.1 g/dL indicates portal hypertension). 1, 2
- Neutrophil count and culture to diagnose SBP (≥250 cells/mm³ is diagnostic). 1, 3, 2
- Ascitic amylase only when pancreatic disease is clinically suspected. 1
Post-Paracentesis Albumin Replacement
For paracentesis >5 liters, infuse 20% or 25% albumin at 8 g per liter of ascites removed after paracentesis is complete to prevent post-paracentesis circulatory dysfunction, renal impairment, and severe hyponatremia. 1, 3, 2 This is critical for preventing mortality.
For paracentesis <5 liters of uncomplicated ascites, synthetic plasma expanders (150-200 mL of gelofusine or haemaccel) are sufficient and albumin is not required. 1
Management of Spontaneous Bacterial Peritonitis
If the ascitic fluid neutrophil count is ≥250 cells/mm³, immediately start empiric antibiotic therapy with intravenous cefotaxime 2 g every 8 hours without waiting for culture results. 1 Third-generation cephalosporins have been most extensively studied and proven effective. 1
For patients with SBP and signs of developing renal impairment (elevated or rising creatinine), administer albumin at 1.5 g/kg within the first 6 hours followed by 1 g/kg on day 3 to prevent hepatorenal syndrome. 1, 2 This significantly reduces mortality.
After recovery from SBP, initiate prophylaxis with continuous oral norfloxacin 400 mg daily or ciprofloxacin 500 mg once daily. 1
Prevention of Ascites Reaccumulation
Initiate sodium restriction to 88 mmol per day (2000 mg per day) and start spironolactone monotherapy at 100 mg daily, increasing to 400 mg daily as needed. 1, 2 Spironolactone is the first-line diuretic because its natriuretic potency is greater than loop diuretics in patients with marked sodium retention. 1
If spironolactone alone fails to resolve ascites, add furosemide up to 160 mg daily with careful biochemical and clinical monitoring. 1, 2 Monitor serum potassium within 1 week of initiation or titration and regularly thereafter, as spironolactone can cause hyperkalemia. 4
Fluid restriction is not necessary unless serum sodium falls below 120-125 mmol/L. 1
Management of Refractory Ascites
For patients requiring frequent therapeutic paracentesis despite maximal diuretic therapy (spironolactone 400 mg and furosemide 160 mg daily), consider transjugular intrahepatic portosystemic shunt (TIPS) with appropriate risk-benefit assessment. 1, 2 Exercise caution with TIPS in patients with age >70 years, serum bilirubin >50 μmol/L, platelet count <75×10⁹/L, MELD score ≥18, current hepatic encephalopathy, or active infection. 2
Critical Pitfalls to Avoid
Never delay antibiotic therapy while waiting for culture results if the neutrophil count is ≥250 cells/mm³—empiric treatment must start immediately as mortality increases with delays. 3
Never perform large volume paracentesis (>5 L) without albumin replacement, as this consistently causes circulatory dysfunction and increases mortality risk. 3 Synthetic colloids are inadequate for large volumes.
Never assume coagulopathy is a contraindication or routinely transfuse blood products prophylactically, as this wastes resources and exposes patients to unnecessary transfusion risks without improving safety. 3
Avoid nonsteroidal anti-inflammatory drugs in patients with ascites, as they reduce urinary sodium excretion and can convert diuretic-sensitive patients to refractory ascites. 1
Liver Transplantation Evaluation
The development of ascites is an important landmark indicating poor prognosis and should prompt consideration for liver transplantation evaluation. 1, 2 All patients with SBP should be considered for transplantation referral. 1 Liver transplantation is the ultimate treatment for ascites and its complications. 1