๐ฅSmith ๐ฆ๐ต ๐ข๐ญ. reported draining a world record of 41 ๐น๐ถ๐๐ฟ๐ฒ๐ of ascitic fluid in a single paracentesis session of a patient with decompensated cirrhosis.
How much Albumin would be needed in this case to prevent post paracentesis circulatory dysfunction ? ๐งต Read on๐
A ๐งต on important points to consider while performing Large Volume Paracentesis (LVP)
๐๐ฐ๐ธ ๐ฎ๐ถ๐ค๐ฉ ๐ข๐ญ๐ฃ๐ถ๐ฎ๐ช๐ฏ ๐ช๐ด ๐ต๐ฐ ๐ฃ๐ฆ ๐ช๐ฏ๐ง๐ถ๐ด๐ฆ๐ฅ ๐ฅ๐ถ๐ณ๐ช๐ฏ๐จ ๐ฑ๐ฆ๐ณ๐ง๐ฐ๐ณ๐ฎ๐ช๐ฏ๐จ ๐๐๐โ๏ธ
๐๐ฉ๐ข๐ต ๐ช๐ด ๐ต๐ฉ๐ฆ ๐ฎ๐ข๐น๐ช๐ฎ๐ถ๐ฎ ๐ข๐ฎ๐ฐ๐ถ๐ฏ๐ต ๐ฐ๐ง ๐ข๐ด๐ค๐ช๐ต๐ช๐ค ๐ง๐ญ๐ถ๐ช๐ฅ ๐ต๐ฉ๐ข๐ต ๐ค๐ข๐ฏ ๐ฃ๐ฆ ๐ฅ๐ณ๐ข๐ช๐ฏ๐ฆ๐ฅโ๏ธ
๐Large Volume Paracentesis(LVP)
is arbitrarily defined as a paracentesis with >5 L of ascitic fluid drained.
In patients undergoing LVP, the use of albumin is crucial to prevent a further reduction of effective arterial blood volume, which may precipitate postparacentesis circulatory dysfunction (PPCD).
The clinical manifestations of PPCD include renal impairment, including HRS, dilutional hyponatremia, hepatic encephalopathy and death.
Albumin infusion is particularly important if more than 5 L of ascites are removed to prevent the development of PPCD.
Paracenteses of a smaller volume(<5L) are not associated with significant hemodynamic changes and albumin infusion may not be required.
Although there has not been a doseโresponse study on albumin use with LVP, the administration of 6โ8 g of albumin per liter of ascites removed has been recommended.
๐ฅFor example, after the fifth liter, approximately 40 g of albumin should be infused, and after 8 L removal, the amount of albumin given should be approximately 64 g.
It has been held that there is no limit for the amount of ascites that can be removed in a single session, provided an appropriate amount of albumin is administered.
However, the risk of PPCD increases with >8 L of fluid evacuated in one single session.
A study showed that by limiting the LVP volume to <8 L per session and providing a higher than recommended dose of albumin (9.0 ยฑ 2.5 g per liter of ascites removed), renal function and survival may be better preserved over a mean period of 2 years despite the development of PPCD in 40% of patients.
In patients with hemodynamic instability (systolic blood pressure <90 mm Hg), hyponatremia (serum sodium <130 mmol/L), and/or the presence of AKI, albumin infusion should be strongly considered for paracentesis of a smaller volume.
LVP is a safe procedure even in the presence of coagulopathy. In a study that included patients with an international normalized ratio of >1.5 and a platelet count of <50 ร 109/L, only 1% of patients experienced minimal cutaneous bleeding after LVP.
Therefore, elevated prothrombin time or thrombocytopenia is not a contraindication for paracentesis, nor is transfusion of clotting factors or platelets recommended.
Possible exceptions may include patients with disseminated intravascular coagulation or uremia with thrombocytopenia.
1/3 ๐ ๐พ๐ค๐ฃ๐ฉ.
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How much Albumin would be needed in this case to prevent post paracentesis circulatory dysfunction ? ๐งต Read on๐
A ๐งต on important points to consider while performing Large Volume Paracentesis (LVP)
๐๐ฐ๐ธ ๐ฎ๐ถ๐ค๐ฉ ๐ข๐ญ๐ฃ๐ถ๐ฎ๐ช๐ฏ ๐ช๐ด ๐ต๐ฐ ๐ฃ๐ฆ ๐ช๐ฏ๐ง๐ถ๐ด๐ฆ๐ฅ ๐ฅ๐ถ๐ณ๐ช๐ฏ๐จ ๐ฑ๐ฆ๐ณ๐ง๐ฐ๐ณ๐ฎ๐ช๐ฏ๐จ ๐๐๐โ๏ธ
๐๐ฉ๐ข๐ต ๐ช๐ด ๐ต๐ฉ๐ฆ ๐ฎ๐ข๐น๐ช๐ฎ๐ถ๐ฎ ๐ข๐ฎ๐ฐ๐ถ๐ฏ๐ต ๐ฐ๐ง ๐ข๐ด๐ค๐ช๐ต๐ช๐ค ๐ง๐ญ๐ถ๐ช๐ฅ ๐ต๐ฉ๐ข๐ต ๐ค๐ข๐ฏ ๐ฃ๐ฆ ๐ฅ๐ณ๐ข๐ช๐ฏ๐ฆ๐ฅโ๏ธ
๐Large Volume Paracentesis(LVP)
is arbitrarily defined as a paracentesis with >5 L of ascitic fluid drained.
In patients undergoing LVP, the use of albumin is crucial to prevent a further reduction of effective arterial blood volume, which may precipitate postparacentesis circulatory dysfunction (PPCD).
The clinical manifestations of PPCD include renal impairment, including HRS, dilutional hyponatremia, hepatic encephalopathy and death.
Albumin infusion is particularly important if more than 5 L of ascites are removed to prevent the development of PPCD.
Paracenteses of a smaller volume(<5L) are not associated with significant hemodynamic changes and albumin infusion may not be required.
Although there has not been a doseโresponse study on albumin use with LVP, the administration of 6โ8 g of albumin per liter of ascites removed has been recommended.
๐ฅFor example, after the fifth liter, approximately 40 g of albumin should be infused, and after 8 L removal, the amount of albumin given should be approximately 64 g.
It has been held that there is no limit for the amount of ascites that can be removed in a single session, provided an appropriate amount of albumin is administered.
However, the risk of PPCD increases with >8 L of fluid evacuated in one single session.
A study showed that by limiting the LVP volume to <8 L per session and providing a higher than recommended dose of albumin (9.0 ยฑ 2.5 g per liter of ascites removed), renal function and survival may be better preserved over a mean period of 2 years despite the development of PPCD in 40% of patients.
In patients with hemodynamic instability (systolic blood pressure <90 mm Hg), hyponatremia (serum sodium <130 mmol/L), and/or the presence of AKI, albumin infusion should be strongly considered for paracentesis of a smaller volume.
LVP is a safe procedure even in the presence of coagulopathy. In a study that included patients with an international normalized ratio of >1.5 and a platelet count of <50 ร 109/L, only 1% of patients experienced minimal cutaneous bleeding after LVP.
Therefore, elevated prothrombin time or thrombocytopenia is not a contraindication for paracentesis, nor is transfusion of clotting factors or platelets recommended.
Possible exceptions may include patients with disseminated intravascular coagulation or uremia with thrombocytopenia.
1/3 ๐ ๐พ๐ค๐ฃ๐ฉ.
#MedTwitter #MedEd #MedX
๐ฅIdeal site for needle insertion in abdominal paracentesis
Large Volume Paracentesis ๐
Sources
1.Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and
Hepatorenal Syndrome: 2021 AASLD
journals.lww.com
2. Smith G, Barnard G. Massive volume paracentesis (up to 41 liters) for the outpatient management of ascites. J Clin Gastroenterol 1997; 25:402-3.
3. Sleisenger and Fordtran's Gastrointestinal and Liver Disease Review and Assessment 10th Edition
1.Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and
Hepatorenal Syndrome: 2021 AASLD
journals.lww.com
2. Smith G, Barnard G. Massive volume paracentesis (up to 41 liters) for the outpatient management of ascites. J Clin Gastroenterol 1997; 25:402-3.
3. Sleisenger and Fordtran's Gastrointestinal and Liver Disease Review and Assessment 10th Edition
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