By Aaron Heckelman MD PGY-3
There are two reasons to do a paracentesis in the emergency department: a “diagnostic paracentesis” to evaluate the cause of ascites and look for evidence of infection, and a “therapeutic paracentesis” to relieve discomfort and shortness of breath in a patient with large-volume, tense ascites. The first requires only a few milliliters of fluid be removed, but the second involves removing several liters, and may make ED providers nervous about causing dangerous “fluid shifts” and resultant hypotension and electrolyte imbalances. In both cases, abnormal coagulation studies may discourage the ED provider from attempting either procedure at all. The following is what the literature and specialty societies have to say about these issues:
Do “fluid shifts” really happen after large-volume paracentesis?
Summary: Yes, and they can be dangerous.
The “fluid shifts” we fear are technically called Paracentesis-Induced Circulatory Dysfunction (PICD). PICD is a well-described complication of large-volume paracentesis (defined as >5L removed), and can occur anytime from a few hours to a few days after the procedure. Symptoms are hypotension, hyponatremia, onset of hepatorenal syndrome, faster reaccumulation of ascites, and short-term mortality.1,4
How many liters can you safely take off at once?
Summary: GI docs routinely drain the entire abdomen, regardless of how many liters are in there. There is good evidence that giving IV albumin reduces the incidence of PICD, and experts agree if you take off >5L you should give IV albumin, 6-8g/L removed. If you are removing <5L, there is some evidence (and an expert consensus in America) that the chance of PICD is low and you do not need to give albumin. European experts agree that the risk of PICD is low in this situation, but still recommend giving albumin. Most people use 25% albumin (rather than the 5% formulation.
The most recent (2012) recommendations from the American Association for the Study of Liver Diseases are2:
Post-paracentesis albumin infusion may not be necessary for a single paracentesis of less than 4 to 5 L. (Class I, Level C)
For large-volume paracenteses, an albumin infusion of 6-8 g per liter of fluid removed appears to improve survival and is recommended. (Class IIa, Level A)
The most recent (2010) recommendation from the European Association for the Study of the Liver is3:
In patients undergoing paracentesis of less than 5 L of ascites, the risk of developing post-paracentesis circulatory dysfunction is low. However, it is generally agreed that these patients should still be treated with albumin… (Class I, Level B).
In GI clinics, standard practice for therapeutic paracentesis is to drain the entire abdomen, with no upper limit on the number of liters removed. This has been shown to be safe, as long as IV albumin 6-8g/L removed is given soon after, and improves patient symptoms and quality of life.4-6 The 25% albumin formulation is typically used (rather than the 5% solution) to minimize the amount of IV fluid and sodium given (at UMC, it is also cheaper this way).
The idea that tang off <5L without giving albumin is safe is based on expert consensus, and on one small trial of 12 patients, none of whom had any symptoms or laboratory evidence of even minor PICD after such paracenteses.7
So albumin really matters?
Summary: Yes it most likely does. There is good evidence that giving albumin reduces incidence of PICD, which is a predictor of shortened survival.
Technically only one study, which used no power calculation, has attempted to directly compare 40-week mortality in large volume paracentesis patients with and without albumin. It found no significant difference between the two, though it did find increased rates of PICD in patients not given albumin.16 This PICD finding has been replicated in several other studies, all of which were compiled in a 2012 meta-analysis by Bernardi et al.6 The meta-analysis found that albumin not only reduces PICD in patients receiving large-volume paracentesis, it is likely superior to all other volume expanders and vasoconstrictors that have been tried. Because of albumin’s expense, researchers had studied hypertonic saline, dextran, hetastarch and other synthetic colloids, and had also tried midodrine, terlipressin and norepinephrine. Of these, terlipressin (not available in the USA), had some smaller studies showing noninferiority to albumin, but in the meta-analysis albumin came out ahead.
Because PICD has, in other studies, been associated with decreased survival17,18, it is reasonable to imply, with the understanding that it hasn’t been directly and rigorously proven, that albumin may have a mortality benefit in these large volume paracentesis patients. This is what led to the AASLD and EASL recommendations outlined above.2,3
PT/aPTT – How high is too high? Platelets – How low is too low?
Summary: There are no cutoffs suggested by the evidence or by specialty societies, because these tests are not useful for predicting bleeding in this setting. Up to about 2% of paracentesis patients will have a bleeding complication, but PT/aPTT and platelet count are very poor predictors. Look for other evidence that the patient is likely to bleed, like extensive bruising or a history of bleeding problems as a better predictor.
It is well established in the hematology literature that, though many liver patients are indeed prone to easy bleeding, even markedly abnormal PT/aPTT and platelet counts are poor predictors of bleeding risk in liver failure patients.8-10 Despite this, many physicians balk at performing paracentesis in patients with markedly abnormal coagulation tests, and some even prophylactically give platelets or FFP to all patients pre-procedure. These practices have no evidence base, and are not endorsed by any professional society.2,3
The safety of paracentesis in liver failure patients with abnormal coagulation markers has been well studied, and no studies have found an overall bleeding complication higher than around 2%.11-13 None have found an association with any particular cutoff for INR or platelet count, despite many subjects having INR>2.5 and Plt<50.11-15
In other words, up to 2% of liver failure patients undergoing paracentesis will have a bleeding complication, but there is no evidence that coagulation studies predict who those 2% will be. Some experts recommend looking for other evidence of bleeding risk on history and physical (such as extensive bruising, history of bleeding problems) rather than checking coagulation studies to determine who is safe to tap.13
References
Lindsay et al. “Paracentesis-Induced Circulatory Dysfunction- A Primer for the Interventional Radiologist.” Semin Intervent Radiol 2014; 31: 276-278.
Runyon, B. “Management of Adult Patients with Ascites Due to Cirrhosis: Update 2012.” Hepatology Apr 2013.
European Assoc for the Study of the Liver. “EASL Clinical Practice Guidelines on the Mgmt of Ascites, SBP and Hepatorenal Syndrome in Cirrhosis.” J of Hepatolog 2010. V53: 397-417.
Hsu et al. “Management of Ascites in Patients with Liver cirrhosis: Recent Evidence and Controversies.” J of the Chinese Med Assoc. 76(2013) 123-130.
Cardenas and Gines. “Is Albumin Infusion Necessary After Large-Volume Paracentesis?” Liver International (2009).
Garcia-Comean et al. “Total Therapeutic Paracentesis (TTP) with and without intravenous albumin in the treatment of cirrhotic tense ascites: a randomized controlled trial.” Liver 1993: 13.
Bernardi et al. “Albumin Infusion in Patients Undergoing Large-Volume Paracentesis: A meta-analysis of randomized trials.” Hepatology. V55, Is4. April 2012.
Peltekian et al. “Cardiovascular, Renal and Neurohumoral Responses to Single Large-Volume Paracentesis in Patients with Cirrhosis and Diuretic-Resistant Ascites.” Am J Gastrenterology. March 1997; 92(3).
Tripodi et al. “Abnormalities of Hemostasis and Bleeding in Chronic Liver Disease.” Intern Emerg Med (2010) 5:7-12.
Caldwell et al. “Coagulation Disorders and Hemostasis in Liver Disease: Pathophysiology and critical assessment of current management.”
Mannucci,P. “Abnormal Hemostasis Tests and Bleeding in chronic Liver Disease: Are they related? No.” J of Thrombosis and Haemostasis. 4. 2006.
Runyon, B. “Paracentesis of ascitic fluid: a safe procedure.” Arch Intern Med. Nov 1986. 146.
Webster et al. “Hemorrhagic Complications of Large Volume Abdominal Paracentesis.” Am J of Gastroenterology. Vol 91, No 2. 1996.
Lin et al. “Should Bleeding Tendency Deter Abdominal Paracentesis?” Digestive and Liver Disease 37 (2005).
Grabau et al. “Performance Standards for Therapeutic Abdominal Paracentesis.” Hepatology. V 40, No2. 2004
Bilodeau, P&M. “Severe Haemorrhage Following Abdominal Paracentesis for Ascites in Patients with Liver Disease.” Aliment Pharmacol Ther 2005; 21: 525-529.
Gines, P et al. “Randomized comparative study of therapeutic paracentesis with and without intravenous albumin in cirrhosis.” Gastroenterology. 1988. 94:1493-1502.
Gines, P et al. “Randomized trial comparing albumin, dextran 70, and polygeline in cirrhotic patients with ascites treated by paracentesis.” Gastroenterology. Oct 1996. 111(4): 1002-1010.
Kwok, C et al. “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: 295153.
There are two reasons to do a paracentesis in the emergency department: a “diagnostic paracentesis” to evaluate the cause of ascites and look for evidence of infection, and a “therapeutic paracentesis” to relieve discomfort and shortness of breath in a patient with large-volume, tense ascites. The first requires only a few milliliters of fluid be removed, but the second involves removing several liters, and may make ED providers nervous about causing dangerous “fluid shifts” and resultant hypotension and electrolyte imbalances. In both cases, abnormal coagulation studies may discourage the ED provider from attempting either procedure at all. The following is what the literature and specialty societies have to say about these issues:
Do “fluid shifts” really happen after large-volume paracentesis?
Summary: Yes, and they can be dangerous.
The “fluid shifts” we fear are technically called Paracentesis-Induced Circulatory Dysfunction (PICD). PICD is a well-described complication of large-volume paracentesis (defined as >5L removed), and can occur anytime from a few hours to a few days after the procedure. Symptoms are hypotension, hyponatremia, onset of hepatorenal syndrome, faster reaccumulation of ascites, and short-term mortality.1,4
How many liters can you safely take off at once?
Summary: GI docs routinely drain the entire abdomen, regardless of how many liters are in there. There is good evidence that giving IV albumin reduces the incidence of PICD, and experts agree if you take off >5L you should give IV albumin, 6-8g/L removed. If you are removing <5L, there is some evidence (and an expert consensus in America) that the chance of PICD is low and you do not need to give albumin. European experts agree that the risk of PICD is low in this situation, but still recommend giving albumin. Most people use 25% albumin (rather than the 5% formulation.
The most recent (2012) recommendations from the American Association for the Study of Liver Diseases are2:
Post-paracentesis albumin infusion may not be necessary for a single paracentesis of less than 4 to 5 L. (Class I, Level C)
For large-volume paracenteses, an albumin infusion of 6-8 g per liter of fluid removed appears to improve survival and is recommended. (Class IIa, Level A)
The most recent (2010) recommendation from the European Association for the Study of the Liver is3:
In patients undergoing paracentesis of less than 5 L of ascites, the risk of developing post-paracentesis circulatory dysfunction is low. However, it is generally agreed that these patients should still be treated with albumin… (Class I, Level B).
In GI clinics, standard practice for therapeutic paracentesis is to drain the entire abdomen, with no upper limit on the number of liters removed. This has been shown to be safe, as long as IV albumin 6-8g/L removed is given soon after, and improves patient symptoms and quality of life.4-6 The 25% albumin formulation is typically used (rather than the 5% solution) to minimize the amount of IV fluid and sodium given (at UMC, it is also cheaper this way).
The idea that tang off <5L without giving albumin is safe is based on expert consensus, and on one small trial of 12 patients, none of whom had any symptoms or laboratory evidence of even minor PICD after such paracenteses.7
So albumin really matters?
Summary: Yes it most likely does. There is good evidence that giving albumin reduces incidence of PICD, which is a predictor of shortened survival.
Technically only one study, which used no power calculation, has attempted to directly compare 40-week mortality in large volume paracentesis patients with and without albumin. It found no significant difference between the two, though it did find increased rates of PICD in patients not given albumin.16 This PICD finding has been replicated in several other studies, all of which were compiled in a 2012 meta-analysis by Bernardi et al.6 The meta-analysis found that albumin not only reduces PICD in patients receiving large-volume paracentesis, it is likely superior to all other volume expanders and vasoconstrictors that have been tried. Because of albumin’s expense, researchers had studied hypertonic saline, dextran, hetastarch and other synthetic colloids, and had also tried midodrine, terlipressin and norepinephrine. Of these, terlipressin (not available in the USA), had some smaller studies showing noninferiority to albumin, but in the meta-analysis albumin came out ahead.
Because PICD has, in other studies, been associated with decreased survival17,18, it is reasonable to imply, with the understanding that it hasn’t been directly and rigorously proven, that albumin may have a mortality benefit in these large volume paracentesis patients. This is what led to the AASLD and EASL recommendations outlined above.2,3
PT/aPTT – How high is too high? Platelets – How low is too low?
Summary: There are no cutoffs suggested by the evidence or by specialty societies, because these tests are not useful for predicting bleeding in this setting. Up to about 2% of paracentesis patients will have a bleeding complication, but PT/aPTT and platelet count are very poor predictors. Look for other evidence that the patient is likely to bleed, like extensive bruising or a history of bleeding problems as a better predictor.
It is well established in the hematology literature that, though many liver patients are indeed prone to easy bleeding, even markedly abnormal PT/aPTT and platelet counts are poor predictors of bleeding risk in liver failure patients.8-10 Despite this, many physicians balk at performing paracentesis in patients with markedly abnormal coagulation tests, and some even prophylactically give platelets or FFP to all patients pre-procedure. These practices have no evidence base, and are not endorsed by any professional society.2,3
The safety of paracentesis in liver failure patients with abnormal coagulation markers has been well studied, and no studies have found an overall bleeding complication higher than around 2%.11-13 None have found an association with any particular cutoff for INR or platelet count, despite many subjects having INR>2.5 and Plt<50.11-15
In other words, up to 2% of liver failure patients undergoing paracentesis will have a bleeding complication, but there is no evidence that coagulation studies predict who those 2% will be. Some experts recommend looking for other evidence of bleeding risk on history and physical (such as extensive bruising, history of bleeding problems) rather than checking coagulation studies to determine who is safe to tap.13
References
Lindsay et al. “Paracentesis-Induced Circulatory Dysfunction- A Primer for the Interventional Radiologist.” Semin Intervent Radiol 2014; 31: 276-278.
Runyon, B. “Management of Adult Patients with Ascites Due to Cirrhosis: Update 2012.” Hepatology Apr 2013.
European Assoc for the Study of the Liver. “EASL Clinical Practice Guidelines on the Mgmt of Ascites, SBP and Hepatorenal Syndrome in Cirrhosis.” J of Hepatolog 2010. V53: 397-417.
Hsu et al. “Management of Ascites in Patients with Liver cirrhosis: Recent Evidence and Controversies.” J of the Chinese Med Assoc. 76(2013) 123-130.
Cardenas and Gines. “Is Albumin Infusion Necessary After Large-Volume Paracentesis?” Liver International (2009).
Garcia-Comean et al. “Total Therapeutic Paracentesis (TTP) with and without intravenous albumin in the treatment of cirrhotic tense ascites: a randomized controlled trial.” Liver 1993: 13.
Bernardi et al. “Albumin Infusion in Patients Undergoing Large-Volume Paracentesis: A meta-analysis of randomized trials.” Hepatology. V55, Is4. April 2012.
Peltekian et al. “Cardiovascular, Renal and Neurohumoral Responses to Single Large-Volume Paracentesis in Patients with Cirrhosis and Diuretic-Resistant Ascites.” Am J Gastrenterology. March 1997; 92(3).
Tripodi et al. “Abnormalities of Hemostasis and Bleeding in Chronic Liver Disease.” Intern Emerg Med (2010) 5:7-12.
Caldwell et al. “Coagulation Disorders and Hemostasis in Liver Disease: Pathophysiology and critical assessment of current management.”
Mannucci,P. “Abnormal Hemostasis Tests and Bleeding in chronic Liver Disease: Are they related? No.” J of Thrombosis and Haemostasis. 4. 2006.
Runyon, B. “Paracentesis of ascitic fluid: a safe procedure.” Arch Intern Med. Nov 1986. 146.
Webster et al. “Hemorrhagic Complications of Large Volume Abdominal Paracentesis.” Am J of Gastroenterology. Vol 91, No 2. 1996.
Lin et al. “Should Bleeding Tendency Deter Abdominal Paracentesis?” Digestive and Liver Disease 37 (2005).
Grabau et al. “Performance Standards for Therapeutic Abdominal Paracentesis.” Hepatology. V 40, No2. 2004
Bilodeau, P&M. “Severe Haemorrhage Following Abdominal Paracentesis for Ascites in Patients with Liver Disease.” Aliment Pharmacol Ther 2005; 21: 525-529.
Gines, P et al. “Randomized comparative study of therapeutic paracentesis with and without intravenous albumin in cirrhosis.” Gastroenterology. 1988. 94:1493-1502.
Gines, P et al. “Randomized trial comparing albumin, dextran 70, and polygeline in cirrhotic patients with ascites treated by paracentesis.” Gastroenterology. Oct 1996. 111(4): 1002-1010.
Kwok, C et al. “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: 295153.
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