1. R Balasubramanya, MD G J Gavern, DO N Hakakian, MD S Simmons, MD
Large Volume Paracentesis: Review of the Complications and Post Operative Management
R Balasubramanya, MD
G J Gavern, DO
N Hakakian, MD
S Simmons, MD
Mercy Catholic Medical Center
Darby, Pennsylvania

2. No commercial interest to disclose
Disclosures
No commercial interest to disclose

3. OBJECTIVES Review the common indications for large volume paracentesis
Review commonly encountered complications of the procedure
Review the necessity of albumin in large volume paracentesis based on American Association for the Study of Liver Diseases (AASL) guidelines and meta-analysis of multiple Randomized Trials

4. INTRODUCTION Definition:
Ascites is defined as accumulation of free fluid in the peritoneal cavity.
Upto 20 ml of fluid is physiological in females
Development of one episode of ascites is associated with 3-year mortality rate of 50%.
Development of refractory ascites is associated with 1- year survival rate of less than 50%

5. Etiology of ascites Malignant conditions Hepatocellular carcinoma
Benign conditions
Cirrhosis
Hepatic congestion
Alcoholic hepatitis
Congestive cardiac failure
Constrictive pericarditis
Tricuspid insufficiency
Budd Chiari Syndrome
Fulminant hepatic failure
Nephrotic syndrome
Protein-losing enteropathy
Severe malnutrition with anasarca
Chylous ascites
Pancreatic ascites
Bile ascites
Bacterial peritonitis
Tuberculous peritonitis
Fungal peritonitis
Human immunodeficiency virus (HIV)-associated peritonitis
Malignant conditions
Hepatocellular carcinoma
Hepatic metastases
Peritoneal carcinomatosis
Pseudomyxoma peritonei
Primary mesothelioma

6. Large Volume Paracentesis
Indicated :
Refractory ascites
Tense ascites
Volume removed >5L

7. Refractory ascites:
Diuretic resistant ascites :lack of response to dietary sodium restriction and intensive diuretic treatment
Diuretic intractable ascites: diuretic-induced complications that preclude the use of an effective diuretic dosage

8. The International Ascites Club Definition  Revised Diagnostic Criteria of Refractory Ascites
1. Treatment duration: patients must be on intensive diuretic therapy (spironolactone 400 mg by mouth daily and furosemide 160 mg by mouth daily) for at least 1 week and on a sodium restricted diet of less than 90 mmol/L per day or 5.2 g of salt (NaCl) per day.
2. Lack of response: mean weight loss of <0.8 kg over 4 days and urinary sodium output less than the sodium intake.
3. Early ascites recurrence: reappearance of grade 2 or 3 ascites within 4 weeks of initial mobilization.
Grade 2-Moderate ascites evident by moderate symmetrical distension of abdomen
Grade 3-Large or gross ascites with marked abdominal distension
4. Diuretic-induced complications
a. Diuretic-induced hepatic encephalopathy: development of encephalopathy in the absence of any other precipitating factor.
b. Diuretic-induced renal impairment: increase of serum creatinine by >100% to a value >2 mg/dL in patients with ascites responding to diuretics.
c. Diuretic-induced hyponatremia: decrease of serum sodium by >10 mmol/L to a serum sodium of <125 mmol/L.
d. Diuretic-induced hypo- or hyperkalemia: change in serum potassium to <3 mmol/L or >6 mmol/L despite appropriate measures.

9. Treatment of refractory ascites
TIPS
Transhepatic Intrajugular Portosystemic Shunt
Orthotopic Liver transplant
Paracentesis
1.First line of treatmenta
2. Fast
3. Effective
4. Few complications
1.Also effective for diuretic refractory ascites
2.Requires conscious sedation or general anesthesia
3.Recurrence of ascites
4.Hepatic encephalopathy
5.High costs
1. Ultimate treatment in patients with advanced liver disease
2. Large discrepancy between patients awaiting and those undergoing transplant
3. Repeated paracentesis and TIPS bridge the time gap before liver transplant
a- Recommended by Consensus Conference of the International Ascites Club

10. Technique
Obtain informed written consent. Explain risk and benefits of the procedure
Position: supine with head elevated to 20 degrees
Use ultrasound to determine largest collection of fluid. A hardcopy image should be obtained.
Sterile prep and drape the site. Use2% Lidocaine for local anesthesia
Avoid:
Midline and far-lateral sites
Areas of skin infection
previous scarring
engorged veins.

11. B A Access largest collection using a 21 gauge micropuncture needle.
Guide wire needle exchange and subcutaneous tract dilatation followed by placement of a 5 Fr multiple side hole catheter B A
A.5 Fr multiple side hole catheter
B. Magnified view of the tip

12. Alternative method: One step procedure with Yueh needle.B A
A.5 Fr 10cm Yueh centesis disposable needle
B. Magnified view of the tip

13. Frequency of paracentesis
Serial large-volume paracenteses (5-10 L) are safe in controlling refractory ascites.
Depends on compliance with low sodium diet.

14. Reasoning behind frequency of paracentesis+
Urine sodium output =0
Dietary intake
+88mmol/day
Non urinary losses
-10mmol/day
Sodium accumulation of
+78mmol/day + + =
Total accumulated in 10 days is 780 mmol
Sodium removed mmol
Sodium content of ascitic fluid is 130mmol/L X
6l of paracentesis =
6 L paracentesis removes the sodium retained over a period of 10 days
No Urine sodium excretion
Sodium restricted diet
(88mmol/day)
Paracentesis required every days

15. Complications of large volume paracentesis
Bleeding
Abdominal wall hematoma (1%)
Hemoperitoneum (0.01% )
Infection:
Site Infection (0.01%)
Secondary bacterial peritonitis-rare case reports1
Leakage-rare with present day technique and 5Fr catheters
Paracentesis induced circulatory dysfunction (PICD)
1- Secondary bacterial peritonitis due to Listeria monocytogenes after paracentesis. South Med J Feb;83(2):213-4

16. Bleeding Most patients have baseline coagulopathy or thrombocytopenia
However, risk of bleeding is very low
Severe hemorrhage is <0.2% of procedures1
Even with INR >1.5 and platelet count <50,000/dl, only minor cutaneous bleeding was noted2
Some studies have reported no hemorrhagic complications despite
no prophylactic transfusions
platelet counts as low as 19,000 cells/mm3 (19 × 106/L) (54% <50,000),
INR as high as 8.7 (75% >1.5 and 26.5% >2.0)3
Contraindication: disseminated intravascular coagulation.
1-Paracentesis .Todd W. Thomsen, M.D., Robert W. Shaffer, M.D., Benjamin White, M.D., and Gary S. Setnik, M.D.N Engl J Med 2006; 355:e21
2-Albumin Infusion in Patients Undergoing Large-Volume. Paracentesis: A Meta-Analysis of Randomized Trials. Mauro Bernardi,1 Paolo Caraceni, Roberta J. Navickis, and Mahlon M. Wilkes. Hepatology. 2012;55:
3- Grabau CM, Crago SF, Hoff LK, Simon JA, Melton CA, Ott BJ, et al. Performance standards for therapeutic abdominal paracentesis. HEPATOLOGY 2004; 40: 484–488.

17. Clinical Practice Guidelines by Society of Interventional Radiology for paracentesis
Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous Image-guided Interventions 2011 :
Paracentesis is a Category 1 procedure
:Procedures with Low Risk of Bleeding, Easily Detected and Controllable
Preprocedure laboratory testing
INR: routinely recommended for patients receiving warfarin anticoagulation or known or suspected liver disease
Platelet count: not routinely recommended
Management
INR 2.0: threshold for treatment (ie, FFP, vitamin K)
Platelets: transfusion recommended for counts 50,000/L
Clopidogrel: withhold for 5 d before procedure
Aspirin: do not withhold
LMWH (therapeutic dose): withhold one dose before procedure

18. Paracentesis induced circulatory dysfunction (PICD)
Controversial
First described by Gines et al, 1988
Defined as increase in plasma renin activity (PRA) of more than 50% of pretreatment value to a level greater than 7.5ng /ml/ hour on the 6th day after paracentesis
Seen up to 6 days after the paracentesis
Patients are asymptomatic
Hyperdynamic state:
Related to activation of the renin-angiotensin system
Associated with rapid re-accumulation of ascites
Water retention leading to dilutional hyponatremia
Portal pressure increases from increased intrahepatic resistance due to the action of vasoconstrictor systems on the hepatic vascular bed
Development of circulatory dysfunction is associated with shortened survival as per some studies1
Not associated with significant mortality or morbidity as per some studies2
1.EASL (European Association for the Study of the Liver Diseases) clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. Journal of Hepatology 2010 vol. 53 j 397–417
2. Management of adult patients with ascites due to cirrhosis: An update. Bruce A. Runyon Hepatology Volume 49, Issue 6, pages 2087–2107, June 2009

19. Volume expanders Albumin infusion recommended to
to minimize intravascular hypovolemia
decrease activation of vaso-constrictor and antinatriuretic systems- leading to electrolyte imbalance
Minimize impairment of renal function.
Albumin is given as 5g/l for every liter removed greater them 5L
Terlipressin can also be to avoid circulatory dysfunction after large volume paracentesis
Non albumin plasma expanders:
dextran 70
hydroxyethylstarch

20. Most studies addressing PICD using plasma expanders have the following exclusion criteria1
Respiratory Failure
Cardiac Failure
Renal Failure
Non cirrhotic ascites :
tuberculosis
peritoneal carcinomatosis
Active gastrointestinal bleeding or history in the preceding month
Spontaneous bacterial peritonitis and hepatic encephalopathy grade 2 or more
Evidence of hepatocellular carcinoma
Treatment with β-blockers for prophylaxis of variceal bleeding
Systemic sepsis within the past month
Platelet count less than 30×103 /mm3
Prothrombin concentration less than 30%
1- Paracentesis: A Meta-Analysis of Randomized Trials
Mauro Bernardi,1 Paolo Caraceni,1 Roberta J. Navickis,2 and Mahlon M. Wilkes. (HEPATOLOGY 2012;55:

21. From our institutional quality assurance data
Ascites requiring paracentesis
Cirrhosis
ESRD
CHF
Most patients requiring large volume serial paracentesis fall into the following categories
Malignancy
Malignancy

22. Is albumin really necessary?
In a routine clinical setting most patients have multiple comorbidities including ESRD and Congestive Heart failure (CHF)
Renal failure was excluded in 17/17 trials included in a metaanalysis study *
Any electrolyte imbalance can be corrected during dialysis
Studies which recommend plasma expanders have excluded patients with malignancies *
14/17 studies excluded liver malignancy
Most patients requiring serial large volume paracentesis have underlying malignancy like hepatocellular carcinoma or peritoneal carcinomatosis from a primary malignancy
*- Paracentesis: A Meta-Analysis of Randomized Trials
Mauro Bernardi,1 Paolo Caraceni,1 Roberta J. Navickis,2 and Mahlon M. Wilkes. (HEPATOLOGY 2012;55:

23. Recommendations by National Guideline Clearinghouse & American Association for the Study of Liver Diseases
Management of adult patients with ascites due to cirrhosis: an update.
For large-volume paracentesis, an albumin infusion of 6 to 8 g/L of fluid removed can be considered (Class IIa, Level C).
Grading System for Recommendations
Class I Conditions for which there is evidence and/or general agreement that a given diagnostic evaluation, procedure or treatment is beneficial, useful, and effective
Class II Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a diagnostic evaluation, procedure, or treatment
Class IIa Weight of evidence/opinion is in favor of usefulness/efficacy
Class IIb Usefulness/efficacy is less well established by evidence/opinion
Class III Conditions for which there is evidence and/or general agreement that a diagnostic evaluation, procedure/treatment is not useful/effective and in some cases may be harmful
Rating Scheme for the Strength of the Evidence
Levels of Evidence
Level A Data derived from multiple randomized clinical trials or meta-analyses
Level B Data derived from a single randomized trial, or nonrandomized studies
Level C Only consensus opinion of experts, case studies, or standard-of-care .

24. Other factors to be considered
High cost of albumin
Complications associated with theoretical risk of viral disease transmission

25. Conclusions
Large volume paracentesis is the first line of treatment for refractory and tense ascites.
Large volume paracentesis (>5l) can be safely performed without albumin replacements in patients
With multiple co morbidities like ESRD, CHF
Underlying malignancy and peritoneal metastasis
Most studies advocating the use of albumin replacements have excluded this group of patients in evaluating the efficacy of albumin replacements and the results cannot be interpolated to patients with these comorbidities.

26. References
American Association for the Study of Liver Diseases. Management of adult patients with ascites due to cirrhosis. National Guideline Clearinghouse. Available at Accessed March 20, 2009.
Paracentesis .Todd W. Thomsen, M.D., Robert W. Shaffer, M.D., Benjamin White, M.D., and Gary S. Setnik, M.D.N Engl J Med 2006; 355:e21
Albumin Infusion in Patients Undergoing Large-Volume. Paracentesis: A Meta-Analysis of Randomized Trials. Mauro Bernardi,1 Paolo Caraceni, Roberta J. Navickis, and Mahlon M. Wilkes. Hepatology ;55:
EASL (European Association for the Study of the Liver Diseases) clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. Journal of Hepatology 2010 vol. 53 j 397–417
Management of adult patients with ascites due to cirrhosis: An update. Bruce A. Runyon Hepatology Volume 49, Issue 6, pages 2087–2107, June 2009

27. Secondary bacterial peritonitis due to Listeria monocytogenes after paracentesis. South Med J Feb;83(2):213-4
Refractory Ascites. Pathogenesis, Clinical Impact, and Management. F Siqueira et al. Gastroenterol Hepatol (N Y) September; 5(9): 647–656.
Grabau CM, Crago SF, Hoff LK, Simon JA, Melton CA, Ott BJ, et al. Performance standards for therapeutic abdominal paracentesis. HEPATOLOGY 2004; 40: 484–488.
Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous Image-guided Interventions. Indravadan J. Patel et al. J Vasc Interv Radiol 2012; 23:727–736