Therapeutic Taps – Why you should establish a day-case outpatient paracentesis clinic if you don’t already have one.
Ascites is common secondary complication to liver cirrhosis. Often hospitals manage patients with refractory or large volume abdominal fluid build-up by admitting them to a ward for paracentesis. It has become an embedded method of management on hep wards to use a suprapubic catheter off licence as the ascitic drain due to certain features that make it preferable to clinical staff. Patients who have ward based therapeutic taps with the off licence suprapubic catheter tend to be admitted for an overnight stay, with the ascitic fluid drained slowly over 6 to 12hr period alongside administering an intermittent infusion of albumin.
Contrary to this method of management, the UK guidance recommends that:
- Paracentesis of <5 litre of uncomplicated ascites should be followed by plasma expansion with a synthetic plasma expander and does not require volume expansion with albumin (Level of evidence: 2b; recommendation: B.)
- Large volume paracentesis >5 litre should be performed in a single session with volume expansion being given once paracentesis is complete, preferably using 8 g albumin/litre of ascites removed (that is, ,100 ml of 20% albumin/3 l ascites). (Level of evidence: 1b; recommendation: A.)
Author recommendations for total paracentesis in a single session are as below:
‘All ascitic fluid should be drained to dryness in a single session as rapidly as possible over 1–4 hours, assisted by gentle mobilisation of the cannula or turning the patient on to their side if necessary. In the author’s opinion, the drain should not be left in overnight’.
The reason why some consultants may be reluctant to change the current procedure may be related to the fact that historically, total large volume paracentesis (>10L) has been wrongly assumed to lead to circulatory collapse*.
However, some NHS hospitals have pressed forward with the BSG guidance and have created business cases to establish small nurse-led paracentesis teams to run day case services where patients are seen as outpatients & total paracentesis is carried out in the recommended time frame of 1-4 hours. This increases the patient footfall, increases the earning potential of the hospital, frees up hospital beds & consultant time and finally results in a better patient experience.
The requirements for a successful service would involve a competent overseeing Heptologist with knowledge of HRG coding, development of nurse competency in ultrasound imaging & a direct puncture multipurpose drainage catheter with excellent flow rates. Contact us for support establishing a nurse-led paracentesis outpatient service.
UK Medical multipurpose drainage catheter, Neo-Hydro: