Category: Critical Care
Keywords: Paracentesis, cirrhosis, ascites, critical care (PubMed Search)
Posted: 9/1/2015 by Daniel Haase, MD
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Your ESLD patient is hypotensive with a tense abdomen, and he needs a paracentesis!
--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].
--Hemorrhage from paracentesis is exceedingly rare, and reversal of mild coagulopathy probably isn't that important [3-4].
--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].
--Albumin replacement improves mortality and incidence of renal failure in patients with SBP or other infection [6-7].
1. Hatch N, Wu TS, Barr L, Roque PJ. Advanced ultrasound procedures. 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.
2. Thomsen TW, Shaffer RW, White B, Setnik GS. Videos in clinical medicine. Paracentesis. 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.
3. Pache I, Bilodeau M. Severe haemorrhage following abdominal paracentesis for ascites in patients with liver disease. Aliment Pharmacol Ther. 2005 Mar 1;21(5):525-9. PubMed PMID: 15740535.
4. McVay PA, Toy PT. Lack of increased bleeding after paracentesis and thoracentesis in patients with mild coagulation abnormalities. Transfusion. 1991 Feb;31(2):164-71. PubMed PMID: 1996485.
5. Nadir A, Van Thiel DH. Frequency of peritoneal infections among patients undergoing continuous paracentesis with an indwelling catheter. J Ayub Med Coll Abbottabad. 2010 Jan-Mar;22(1):37-41.
6. Kwok CS, Krupa L, Mahtani A, Kaye D, Rushbrook SM, Phillips MG, Gelson W. Albumin reduces paracentesis-induced circulatory dysfunction and reduces death and renal impairment among patients with cirrhosis and infection: a systematic review and meta-analysis. Biomed Res Int. 2013;2013:295153. doi: 10.1155/2013/295153. Epub 2013 Oct 8. Review. PubMed PMID: 24222902; PubMed Central PMCID: PMC3816020.
7. Sort P, Navasa M, Arroyo V, Aldeguer X, Planas R, Ruiz-del-Arbol L, Castells L, Vargas V, Soriano G, Guevara M, Gin s P, Rod s J. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med. 1999 Aug 5;341(6):403-9. PubMed PMID: 10432325.
1509011640_Figure_1_--_Ascites_pocket.jpg (78 Kb)
1509011640_Figure_2_--_Color_over_abd_wall_varices.jpg (89 Kb)
