In a patient with decompensated cirrhosis who had large‑volume paracentesis with 5 L removed and only 20 g albumin administered, now presenting with abdominal distension, perineal edema, back pain and infusion‑site pain without fever, what immediate management steps are indicated?

Immediate Management of Post-Paracentesis Complications with Inadequate Albumin Replacement

This patient received only 20 g albumin for 5 L of ascites removal—exactly half the mandatory dose—and is now experiencing post-paracentesis circulatory dysfunction (PICD) with fluid redistribution; immediately administer the remaining 20 g of albumin (100 mL of 20% solution) and closely monitor for hepatorenal syndrome over the next 6 days. 1, 2

Critical Error in Initial Management

• The standard dose is 8 g albumin per liter of ascites removed for volumes >5 L, meaning this patient required 40 g total but received only 20 g—a 50% underdose. 1, 2
• This underdosing significantly increases the risk of PICD, which manifests as renal impairment (21% vs 0% with adequate albumin), hyponatremia, and marked activation of the renin-angiotensin-aldosterone system. 1, 3
• Without adequate albumin replacement, up to 70% of patients develop PICD, characterized by effective hypovolemia despite total body fluid overload. 1, 4

Understanding the Current Clinical Picture

• The abdominal swelling, perineal edema ("puffed up vagina"), and back pain represent fluid redistribution into third spaces due to inadequate plasma oncotic pressure from albumin deficiency. 1
• The injection site pain is likely related to the paracentesis procedure itself and should resolve, but monitor for signs of infection (though fever is absent). 5
• These symptoms reflect paracentesis-induced circulatory dysfunction with interstitial fluid shifts rather than simple ascites reaccumulation. 4, 3

Immediate Corrective Actions (Within Hours)

• Administer the remaining 20 g of albumin immediately as 100 mL of 20% albumin solution or 80 mL of 25% albumin solution, infused slowly over 1-2 hours to avoid cardiac overload. 1, 2, 4
• Use hyperoncotic 20% or 25% albumin solutions only—5% albumin is inadequate for this indication and increases sodium load five-fold. 1, 2
• Infuse slowly in this patient with decompensated cirrhosis to prevent volume overload, as cirrhotic cardiomyopathy may be present. 1, 4

Critical Monitoring Protocol (Days 1-6)

• Daily serum creatinine measurements to detect acute kidney injury, which occurs significantly more often without adequate albumin (renal impairment developed in 11/53 patients without albumin vs 1/52 with albumin in landmark trials). 3
• Daily serum sodium levels to identify hyponatremia, which develops in 17% with inadequate plasma expansion vs 8% with proper albumin dosing. 1
• Plasma renin activity on day 6 if available—a >50% rise above baseline to >4 ng/mL/h defines PICD and predicts decreased survival. 1, 6
• Mean arterial pressure monitoring—expect modest decreases (<8 mmHg), but watch for more severe hypotension indicating advanced circulatory dysfunction. 1

Diuretic Management

• Reinstitute diuretics within 1-2 days post-paracentesis to prevent ascites reaccumulation, which occurs in 93% without diuretics vs only 18% with spironolactone. 1
• Start with spironolactone 100 mg daily, titrating up to 400 mg if needed, combined with furosemide 40 mg if necessary (maintaining 100:40 mg ratio). 1
• Diuretic reintroduction does not increase PICD risk when adequate albumin has been given. 1

Preventing Future Complications

• For any future paracentesis >5 L, mandate 8 g albumin per liter removed (not 4 g/L as was done here). 1, 2
• Consider limiting single-session paracentesis to <8 L, as PICD risk increases substantially beyond this volume. 1, 5
• Ultrasound guidance should be used for all future procedures to reduce bleeding and other complications. 2, 5

Red Flags Requiring Escalation

• Rising creatinine >0.3 mg/dL from baseline suggests evolving hepatorenal syndrome, which has 21% six-month mortality in refractory ascites. 1
• Serum sodium <125 mEq/L requires fluid restriction to <1000 mL/day and consideration of hypertonic saline. 2
• Worsening hypotension or oliguria despite albumin correction warrants ICU-level monitoring and possible vasoconstrictor therapy. 1, 4
• Development of fever or abdominal pain mandates diagnostic paracentesis to rule out spontaneous bacterial peritonitis (which requires different albumin dosing: 1.5 g/kg within 6 hours, then 1 g/kg on day 3). 1, 2

Long-Term Considerations

• This patient should be evaluated for liver transplantation if not already listed, as refractory ascites requiring large-volume paracentesis carries 21% six-month mortality. 1
• Consider TIPS (transjugular intrahepatic portosystemic shunt) if repeated large-volume paracentesis becomes necessary every 2-3 weeks despite maximal diuretic therapy. 1
• Ensure strict sodium restriction <2 g/day and assess dietary compliance, as poor adherence is the most common reason for frequent paracentesis needs. 2