In a patient with serum albumin 2.1 g/dL, normal blood pressure and massive ascites, can I safely perform a therapeutic paracentesis and what is the maximum volume to remove?

Yes—Proceed with Large-Volume Paracentesis and Remove All Ascites in a Single Session

You can and should perform therapeutic paracentesis in this patient despite the low albumin and massive ascites, removing the entire volume to dryness in one session, provided you administer 8 g of intravenous albumin per liter of ascites removed for volumes exceeding 5 liters. 1, 2

Volume Removal Guidelines

• There is no absolute upper limit on the volume you can safely remove in a single paracentesis session when appropriate albumin replacement is given 2, 3
• Complete drainage to dryness is the recommended approach—historical concerns about hemodynamic collapse from rapid large-volume removal have been disproven 2
• Studies demonstrate safe removal of 10–12 liters over 60–97 minutes without significant hemodynamic compromise (blood pressure changes <8 mmHg) 2, 4, 5
• The procedure should be completed over 1–4 hours at a drainage rate of approximately 2–9 liters per hour 2

Mandatory Albumin Replacement Protocol

For volumes >5 liters:

• Administer 8 g of albumin per liter of ascites removed 1, 2, 6
• Use 20% or 25% albumin solution (e.g., 100 mL of 20% albumin per 3 liters removed) 2, 3
• Infuse albumin after completing the paracentesis, not during the procedure 2, 6
• Deliver over 1–2 hours to avoid volume overload 2

For volumes <5 liters:

• Albumin is not mandatory in uncomplicated cases 2, 3
• Consider albumin (8 g/L) in high-risk patients with acute-on-chronic liver failure or elevated risk of post-paracentesis acute kidney injury 2, 3

Why Albumin is Critical in This Patient

• Without albumin, renal impairment occurs in approximately 21% of patients after large-volume paracentesis, compared with 0% when albumin is administered 2
• Post-paracentesis circulatory dysfunction (PICD) develops in up to 80% without volume expansion but only 18.5% with albumin 3
• Albumin prevents marked elevations in plasma renin activity, aldosterone, and severe hyponatremia that occur without replacement 7
• The low baseline albumin (2.1 g/dL) does not contraindicate paracentesis—the albumin dose is calculated solely on ascites volume removed, not patient body weight or serum albumin level 2

Procedural Technique

• Use ultrasound guidance when available to reduce adverse events 2
• Insert needle in the left lower quadrant (preferred) using Z-track technique (perpendicular skin entry, oblique subcutaneous advancement) 2
• Use a cannula with multiple side perforations to prevent blockage 2
• Do not leave the drain in overnight after completing the procedure 2

Critical Pitfalls to Avoid

• Do not artificially slow the drainage rate out of concern for hemodynamic instability—this outdated practice delays symptom relief and is not supported by current evidence 2
• Do not withhold paracentesis due to coagulopathy or thrombocytopenia—routine correction of INR or platelet count is not recommended, even with INR up to 8.7 or platelets as low as 19×10³/μL 2
• Do not underdose albumin—administering less than 6 g/L is associated with significant increases in PICD and renal complications 2
• Do not use normal saline for volume expansion in this patient—it contains 154 mmol/L sodium and will worsen ascites 3

Post-Procedure Monitoring (First 6 Days)

• Daily serum creatinine to detect acute kidney injury 2
• Daily serum sodium monitoring for hyponatremia 2
• Monitor for plasma renin activity rise >50% from baseline as an early marker of PICD 2

Normal Blood Pressure is Not a Contraindication

• Normal BP does not preclude paracentesis—cirrhotic patients with ascites have effective hypovolemia with peripheral arterial vasodilation despite normal measured BP 8
• The albumin infusion addresses the effective hypovolemia and prevents circulatory dysfunction regardless of baseline BP 8, 7