Paracentesis-induced circulatory dysfunction (PICD)

• Syndrome with fast re-accumulation of ascites, hyponatremia due to natiuresis, renal impairment, and possible mortality

• Risk: high removal rate, large volume paracentesis (generally >6L)

• Pathophysiology: reflex arterial vasodilation from rapidly removed intra-abdominal pressure, increased nitric oxide release from shear stress of increased cardiac output; then increased activation of the renin-angiotensin system and sympathetic systems

• Effects can occur up to 6 days from procedure; dynamic time course

• May occur in up to 80% of patients receiving large volume paracentesis (LVP) of > 6 L who do NOT get plasma expanders

• Occurred in 38% of patients receiving albumin in one study

  • Minimum volume removed 8 L

  • Across literature incidence 15-35% when albumin used

Should plasma expanders routinely be given?

• Strongly consider for paracentesis volumes >5L
• Dose: 6-8 g of colloid per L removed
• Current statement from American Association for the Study of Liver Disease guidelines: reasonable but not mandatory to tx with colloid
• Should admit for hemodynamic monitoring