When to Perform and When to Avoid Paracentesis in Liver Failure with Ascites
Large-volume paracentesis should be performed as first-line therapy for all patients with tense (grade 3) ascites from cirrhosis, completed in a single session with albumin replacement (8 g/L of fluid removed for volumes >5L), and there are essentially no contraindications except disseminated intravascular coagulation, clinically evident hyperfibrinolysis, and uncooperative patients. 1, 2
When to Perform Paracentesis
Primary Indications
- Tense ascites (grade 3) causing respiratory compromise or significant discomfort requires immediate large-volume paracentesis as first-line therapy 1
- New-onset ascites for diagnostic purposes to evaluate for spontaneous bacterial peritonitis, malignancy, or other causes 1
- Refractory ascites that fails to respond adequately to diuretic therapy and sodium restriction 1, 3
Technical Approach
- Drain all ascitic fluid to dryness in a single session over 1-4 hours—do not perform repeated small-volume taps as this increases complication risk without benefit 1, 3
- Use ultrasound guidance when available to reduce adverse events by approximately 68% 1, 2
- Insert needle in the left lower quadrant (preferred site), at least 8 cm from midline and 5 cm above symphysis pubis, where the abdominal wall is thinnest and ascites depth is greatest 1, 2
Albumin Replacement Protocol
- For volumes >5 liters: Mandatory albumin replacement at 8 g per liter of ascites removed (e.g., 100 mL of 20% albumin per 3 liters removed) 1, 3
- For volumes <5 liters: Albumin replacement is not necessary unless the patient has acute-on-chronic liver failure (ACLF), in which case albumin significantly reduces renal impairment, hyponatremia, and death 1, 3
- Infuse albumin after paracentesis is completed, not during the procedure 3, 4
When NOT to Perform Paracentesis
Absolute Contraindications (The Only True Reasons to Avoid)
- Disseminated intravascular coagulation (DIC) with active consumptive coagulopathy and ongoing bleeding 1, 2
- Clinically evident hyperfibrinolysis manifested by three-dimensional ecchymosis or hematoma formation 2
- Uncooperative patient who cannot remain still during the procedure 2
- Abdominal skin infection at the proposed puncture site 2
- Severe bowel distension that significantly increases perforation risk 2
Critical Clarification: What is NOT a Contraindication
Coagulopathy and thrombocytopenia are NOT contraindications to paracentesis. This is a common and dangerous pitfall. 1, 2, 5
- Do not routinely measure PT/INR or platelet count before paracentesis 1, 2
- Do not transfuse fresh frozen plasma or platelets prophylactically, even with INR >1.5 or platelets <50,000/μL 1, 2
- Paracentesis has been safely performed with INR as high as 8.7 and platelet counts as low as 19,000/μL without prophylactic correction 2, 5
- Bleeding complications occur in <0.2% of procedures, and when they do occur, they are associated with severe renal failure, not coagulopathy 5, 6
Relative Contraindications Requiring Caution
- Pregnancy: Use ultrasound guidance if paracentesis is clinically necessary 2
- Loculated ascites: May be technically difficult but not an absolute contraindication 1
Special Populations and Considerations
Fontan Circulation Patients
- TIPS is contraindicated in Fontan patients with refractory ascites due to risk of precipitating cardiac failure from sudden blood volume shift 1
- Repeated paracentesis is the recommended approach for recurrent ascites in this population, not TIPS 1
- Optimize cardiac function and use diuretics as first-line therapy before considering paracentesis 1
Patients on Anticoagulation
- Direct oral anticoagulants (DOACs) like apixaban may increase bleeding risk in patients with cirrhosis and renal impairment, though data are limited 7
- Traditional teaching that paracentesis is safe without interrupting anticoagulation may not apply to all DOACs in cirrhotic patients 7
Post-Paracentesis Management
Prevention of Recurrence
- Initiate or resume diuretics after large-volume paracentesis at the minimum dose necessary to prevent re-accumulation 1, 3
- Sodium restriction to <2 g/day is essential, as paracentesis does not address the underlying sodium and water retention 1, 3
- Fluid restriction to <1,000 mL/day only if hyponatremia <125 mEq/L is present 3, 4
Monitoring for Complications
- Post-paracentesis circulatory dysfunction (PPCD) occurs in up to 80% without albumin but only 18.5% with albumin 4
- PPCD manifests as renal impairment, hyponatremia, hepatic encephalopathy, and hypotension within days after the procedure 4
- Transient decrease in blood cell counts occurs after large-volume paracentesis but is physiological and self-limited 8
Common Pitfalls to Avoid
Do not artificially slow drainage rate out of outdated concern for hemodynamic instability—removal of >10 liters over 2-4 hours causes minimal blood pressure changes 3
Do not perform serial small-volume paracenteses instead of single large-volume drainage—this increases complication risk and offers no benefit 1, 3
Do not withhold paracentesis due to coagulopathy—this is the most common and dangerous misconception 1, 2, 5
Do not omit albumin for volumes >5 liters—this significantly increases mortality, renal dysfunction, and hyponatremia 1, 3, 4
Do not avoid visible collateral vessels in the midline—use the left lower quadrant approach instead 2