How should large‑volume paracentesis (>5 L) be performed and managed in a patient with gross ascites due to decompensated cirrhosis, including ultrasound guidance, correction of coagulopathy, albumin replacement, monitoring, and post‑procedure considerations?

Large-Volume Paracentesis in Gross Ascites: Evidence-Based Protocol

Perform complete drainage to dryness in a single session over 1–4 hours with mandatory albumin replacement at 8 g per liter for volumes >5 L, without any absolute upper volume limit. 1, 2, 3

Pre-Procedure Considerations

Coagulopathy Does NOT Require Correction

• Do not routinely correct INR or platelet count before paracentesis, even with severe coagulopathy (INR up to 8.7 or platelets as low as 19×10³/μL). 1, 2
• Hemorrhagic complications after large-volume paracentesis are infrequent and show no correlation with degree of coagulopathy. 1
• Fresh frozen plasma or pooled platelets are not supported by evidence and should not be given routinely. 1
• The only true contraindication is disseminated intravascular coagulation; loculated ascites is a relative contraindication. 1

Ultrasound Guidance

• Use ultrasound guidance when available to reduce adverse events, though it is not mandatory. 2, 3

Procedure Technique

Needle Insertion

• Insert in the left lower quadrant (preferred) or right lower quadrant, at least 8 cm from midline and 5 cm above symphysis pubis. 2, 3
• Use the "Z-track" technique: perpendicular skin entry with oblique subcutaneous advancement to prevent post-procedure leakage. 2, 3
• Use a cannula with multiple side perforations to prevent blockage by bowel wall. 2

Drainage Protocol

• Remove all ascitic fluid to dryness as rapidly as possible over 1–4 hours in a single session. 2, 3
• Typical drainage rate is 2–9 liters per hour; do not artificially slow the rate out of outdated concerns about hemodynamic instability. 2
• Historical fears about circulatory collapse from rapid removal have been disproven—removing >10 liters over 2–4 hours causes only minimal blood pressure changes (<8 mmHg decrease). 2
• Assist drainage by gentle mobilization of the cannula or turning the patient onto their side if flow slows. 2
• Do not leave the drain in overnight after completing the procedure. 2

Volume Limits and Safety

No Absolute Upper Limit

• There is no absolute upper volume limit for single-session paracentesis when appropriate albumin replacement is administered. 2, 3
• Complete drainage to dryness in a single session is safe and effective. 2, 3
• Some guidelines suggest considering a practical limit of ≤8 liters per session to optimize safety, though this is not mandatory. 3

Albumin Replacement: The Critical Intervention

Mandatory Dosing for >5 L

• Administer 8 g of albumin per liter of ascitic fluid removed when total volume exceeds 5 L. 1, 2, 3
• This translates to approximately 100 mL of 20% albumin per 3 liters of ascites removed. 1, 2
• For example, removing 10 L requires 80 g of albumin (400 mL of 20% albumin or 320 mL of 25% albumin). 2

Timing and Administration

• Infuse albumin AFTER paracentesis is completed, not during the procedure. 2
• Deliver over 1–2 hours to avoid volume overload, especially in patients with cirrhotic cardiomyopathy. 2
• Use hyperoncotic solutions (20% or 25% albumin); 5% albumin is inadequate. 2

For Volumes <5 L

• Albumin replacement is not mandatory for volumes <5 L in uncomplicated cases. 1
• Synthetic plasma expanders (150–200 mL of gelofusine or Haemaccel) are acceptable alternatives for <5 L. 1, 2
• Consider albumin at 8 g/L even for <5 L in patients with acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury. 2

Evidence Supporting Albumin

• Albumin reduces the odds of post-paracentesis circulatory dysfunction (PICD) by 60–61%. 2, 4
• Albumin reduces hyponatremia by 42% and mortality by 36% compared to alternative volume expanders. 2
• Renal impairment occurs in approximately 21% of patients without albumin versus 0% with albumin. 2, 5
• Without albumin, marked elevation of plasma renin activity and aldosterone occurs, along with decreased cardiac output and central venous pressure. 5

Post-Procedure Management

Immediate Monitoring (First 6 Days)

• Daily serum creatinine to detect acute kidney injury, a recognized complication of inadequate albumin replacement. 2
• Daily serum sodium monitoring, as hyponatremia may develop with under-replacement. 2
• Monitor for >50% rise in plasma renin activity from baseline as an early marker of PICD. 2

Post-Procedure Positioning

• Have patient lie on the opposite side for 2 hours if there is leakage of remaining ascitic fluid. 2

Diuretic Therapy

• After large-volume paracentesis, patients require diuretic treatment to prevent re-accumulation of ascites, as paracentesis does not address underlying sodium retention. 1
• Start or resume spironolactone (100–400 mg/day) with furosemide (40–160 mg/day) in a 100:40 mg ratio to maintain normokalemia. 1
• Single morning dosing maximizes compliance. 1

Sodium Restriction

• Restrict dietary sodium to 88 mmol/day (approximately 2 g/day or 5.2 g salt/day), essentially a "no added salt" diet. 1

Critical Pitfalls to Avoid

Underdosing Albumin

• Underdosing albumin below 6 g/L is associated with significant increases in PICD and renal complications. 2
• If underdosing occurs, administer the remaining albumin promptly within hours. 2

Performing Serial Paracenteses Without Diuretics

• Never perform serial paracenteses in diuretic-sensitive patients without initiating diuretic therapy, as this fails to address underlying sodium retention. 1
• Large-volume paracentesis should not be viewed as first-line therapy for all patients with ascites—only for tense or refractory ascites. 1

Artificially Slowing Drainage

• Do not slow drainage rate out of concern for hemodynamic instability; this outdated practice delays symptom relief without evidence of benefit. 2

Withholding Paracentesis for Coagulopathy

• Do not withhold paracentesis due to elevated INR or low platelets; routine correction is not recommended. 1, 2

Drugs to Avoid in Ascites Patients

• NSAIDs (indomethacin, ibuprofen, aspirin, sulindac) cause acute renal failure, hyponatremia, and diuretic resistance. 1
• ACE inhibitors and angiotensin II antagonists induce arterial hypotension and renal failure. 1
• α1-adrenergic blockers (prazosin) impair renal sodium retention and worsen ascites. 1
• Aminoglycosides increase risk of renal failure and should be reserved for infections untreatable with other agents. 1

When to Consider Alternative Therapies

Refractory Ascites

• Defined as ascites unresponsive to maximum diuretic doses (400 mg/day spironolactone and 160 mg/day furosemide) with sodium restriction, or ascites that recurs rapidly after therapeutic paracentesis. 1
• Patients requiring frequent paracentesis (≥2–3 times per month) should be evaluated for transjugular intrahepatic portosystemic shunt (TIPS) if otherwise suitable. 2

Liver Transplantation

• Development of ascites is an indication for liver transplantation evaluation, as it signals poor prognosis with 50% 2-year survival. 1, 6, 7