Title: Abdominal Paracentesis on the Hypotensive Cirrhosis Patient<br/>Author: Daniel Haase<br/><a href='http://umem.org/profiles/faculty/1447/'>[Click to email author]</a><hr/><p>
Your ESLD patient is hypotensive with a tense abdomen, and he needs a paracentesis!</p>
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--ALWAYS use ultrasound to localize a fluid pocket [Fig 1]! Take the time to use color Doppler to look for underlying abdominal wall varices [Fig 2]. Cirrhotic patients frequently have abnormal abdominal wall vasculature [1-2].</p>
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--Hemorrhage from paracentesis is exceedingly rare, and reversal of mild coagulopathy probably isn't that important [3-4].</p>
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--In hypotensive patients, consider placement of a small pigtail catheter for slow, continuous drainage (e.g. 8.3F pericardiocentesis catheter) instead of large-volume paracentesis. Non-tunneled catheter infection risk goes up after 72h [5].</p>
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--Albumin replacement improves mortality and incidence of renal failure in patients with SBP or other infection [6-7]. </p>
<fieldset><legend>References</legend>
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1. Hatch N, Wu TS, Barr L, Roque PJ. <a href="http://www-ncbi-nlm-nih-gov.proxy-hs.researchport.umd.edu/pubmed/24606778">Advanced ultrasound procedures.</a> Crit Care Clin. 2014 Apr;30(2):305-29, vi. doi: 10.1016/j.ccc.2013.10.005. Epub 2013 Dec 4. Review. PubMed PMID: 24606778.</p>
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2. Thomsen TW, Shaffer RW, White B, Setnik GS. <a href="http://www-ncbi-nlm-nih-gov.proxy-hs.researchport.umd.edu/pubmed/17093242">Videos in clinical medicine. Paracentesis.</a> N Engl J Med. 2006 Nov 9;355(19):e21. Erratum in: N Engl J Med. 2007 Feb 15;356(7):760. PubMed PMID: 17093242.</p>
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3. Pache I, Bilodeau M. <a href="http://www-ncbi-nlm-nih-gov.proxy-hs.researchport.umd.edu/pubmed/15740535">Severe haemorrhage following abdominal paracentesis for ascites in patients with liver disease.</a> Aliment Pharmacol Ther. 2005 Mar 1;21(5):525-9. PubMed PMID: 15740535.</p>
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4. McVay PA, Toy PT. <a href="http://www-ncbi-nlm-nih-gov.proxy-hs.researchport.umd.edu/pubmed/1996485">Lack of increased bleeding after paracentesis and thoracentesis in patients with mild coagulation abnormalities.</a> Transfusion. 1991 Feb;31(2):164-71. PubMed PMID: 1996485.</p>
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5. Nadir A, Van Thiel DH. <a href="http://www-ncbi-nlm-nih-gov.proxy-hs.researchport.umd.edu/pubmed/21409900">Frequency of peritoneal infections among patients undergoing continuous paracentesis with an indwelling catheter.</a> J Ayub Med Coll Abbottabad. 2010 Jan-Mar;22(1):37-41.</p>
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6. Kwok CS, Krupa L, Mahtani A, Kaye D, Rushbrook SM, Phillips MG, Gelson W. <a href="http://www-ncbi-nlm-nih-gov.proxy-hs.researchport.umd.edu/pubmed/24222902">Albumin reduces paracentesis-induced circulatory dysfunction and reduces death and renal impairment among patients with cirrhosis and infection: a systematic review and meta-analysis.</a> Biomed Res Int. 2013;2013:295153. doi: 10.1155/2013/295153. Epub 2013 Oct 8. Review. PubMed PMID: 24222902; PubMed Central PMCID: PMC3816020.</p>
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7. Sort P, Navasa M, Arroyo V, Aldeguer X, Planas R, Ruiz-del-Arbol L, Castells L, Vargas V, Soriano G, Guevara M, Ginès P, Rodés J. <a href="http://www-ncbi-nlm-nih-gov.proxy-hs.researchport.umd.edu/pubmed/10432325">Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis.</a> N Engl J Med. 1999 Aug 5;341(6):403-9. PubMed PMID: 10432325.</p>
</fieldset><fieldset><legend>Attachments</legend>
Figure_1_--_Ascites_pocket.jpg (78 Kb)<br/><a href='http://umem.org/files/uploads/1509011640_Figure_1_--_Ascites_pocket.jpg' target='_blank'>http://umem.org/files/uploads/1509011640_Figure_1_--_Ascites_pocket.jpg</a><br/><br/>
Figure_2_--_Color_over_abd_wall_varices.jpg (89 Kb)<br/><a href='http://umem.org/files/uploads/1509011640_Figure_2_--_Color_over_abd_wall_varices.jpg' target='_blank'>http://umem.org/files/uploads/1509011640_Figure_2_--_Color_over_abd_wall_varices.jpg</a><br/><br/></fieldset>