Advanced Practice - Paracentesis-induced circulatory dysfunction (PICD)


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



Lindsay, Aaron J et al. “Paracentesis-Induced Circulatory Dysfunction: A Primer for the Interventional Radiologist.” Seminars Interventional Radiology. 2014 Sep; 31(3): 276–278.

Nasr, G et al. “Predictors of large volume paracantesis induced circulatory dysfunction in patients with massive hepatic ascites.” Journal of Cardiovascular Disease Research. 2010 Jul-Sep; 1(3): 136–14












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