What causes hypotension after paracentesis in patients with cirrhosis (liver scarring)?

From the Guidelines

Hypotension after paracentesis in cirrhosis should be managed with albumin administration at a dose of 6-8 g per liter of ascitic fluid removed when large-volume paracentesis (>5 liters) is performed, as this approach has been shown to be the most effective in preventing post-paracentesis circulatory dysfunction (PICD) 1.

Key Considerations

• The development of PICD is a common complication of large-volume paracentesis, occurring in up to 80% of patients in the absence of volume expansion 1.
• Albumin administration has been shown to be more effective than other plasma expanders, such as dextran-70 and polygeline, in preventing PICD 1.
• The use of albumin is recommended by the International Ascites Club for large-volume paracentesis of >6 L, with a dose of 6-8 g/L of ascitic fluid removed 1.
• For smaller volume paracentesis, albumin may not be necessary, but its use should be considered on a case-by-case basis.

Management of Hypotension

• If hypotension occurs despite albumin administration, intravenous fluid resuscitation with normal saline should be initiated promptly, starting with a 500-1000 mL bolus.
• Vasopressors such as norepinephrine (starting at 0.1-0.5 mcg/kg/min) or midodrine (5-10 mg orally three times daily) may be required for persistent hypotension.

Preventive Measures

• Limiting paracentesis volume when possible, slow fluid removal, and positioning the patient supine during and after the procedure can help prevent PICD.
• Patients should be monitored for at least 1-2 hours post-procedure for signs of hypotension, tachycardia, or dizziness, with vital signs checked every 15-30 minutes initially.

Evidence Summary

• The evidence from recent studies, including those published in 2021 1, supports the use of albumin administration to prevent PICD in patients undergoing large-volume paracentesis.
• The use of albumin has been shown to be cost-effective and associated with a lower number of liver-related complications compared to other plasma expanders 1.

From the Research

Hypotension after Paracentesis in Cirrhosis

• Hypotension is a potential complication after paracentesis in patients with cirrhosis, particularly after large-volume paracentesis (LVP) 2, 3.
• The use of albumin after LVP can reduce the risk of paracentesis-induced circulatory dysfunction (PICD), which can lead to hypotension, hyponatremia, and renal impairment 2.
• A study found that standardizing albumin dosing based on the amount of ascitic fluid removed during LVP resulted in a significant reduction in albumin use without increasing the risk of hypotension or other adverse effects 2.
• Another study suggested that even modest-volume paracentesis (<5 L) can lead to PPCD and hypotension in Asian patients with cirrhosis, particularly those with low baseline serum sodium levels 4.
• The pathophysiology of PICD involves increases in plasma renin activity, which can lead to vasoconstriction and decreased cardiac output, resulting in hypotension 3.
• Hyponatremia, which is common in patients with cirrhosis, can also contribute to the development of hypotension, particularly in advanced cirrhosis 5.
• Factors that can contribute to the development or worsening of hyponatremia and hypotension in cirrhosis include portal hypertension, diuretics, large-volume paracentesis without albumin, infection, and multiple medications 5.