In patients with refractory ascites, therapeutic options may be limited. Patients often require frequent paracentesis.
Although Indwelling peritoneal catheters (IPCs) are typically used in malignant ascites, they can be considered in patients with refractory ascites related to cirrhosis (requiring paracentesis at least monthly despite diuretics).
In a 2019 systematic review, Macken et al. concluded “Despite lack of well-designed studies, preliminary data suggests low significant complication rates; however safety and efficacy of permanent indwelling peritoneal catheters in end-stage liver disease remains to be confirmed”.
A randomized controlled trial by the same authors (PMID 32478917) published in 2020 compared large-volume paracentesis vs long-term abdominal drains in refractory ascites patients who were not candidates for liver transplantation. All participants were given ciprofloxacin 500 mg po daily as antibiotic prophylaxis. No protocolized albumin was given in the long-term abdominal drain arm. Costs and time in hospital were lower in the indwelling drain group and there was no difference in the incidence of peritonitis (6% in the indwelling drain group and 11% in the large- volume paracentesis group.
Placement is generally ordered after consultation with a liver specialist, weighing the risks vs benefits.
Step 1:
Evaluate patient candidacy for other first line therapies for refractory ascites management:
- TIPS
- Liver transplant
Step 2:
Consider potential contraindications to IPC placement:
| Contraindications | Rationale |
|---|---|
| Candidate for liver transplant | Theoretical risk of causing a cocoon abdomen or sclerosing encapsulating peritonitis |
| Fluid septations | Drain will likely not be effective to manage ascites. Can rule out with ultrasound |
| Thin abdominal wall | Can make tunnelling the drain challenging. Pre-insertion consult by an interventional radiologist should be considered in these circumstances |
| Severe abdominal anasarca | Drain insertion site will be less likely to heal, resulting in higher risk for long term leaking from the site Pre-insertion consult by an interventional radiologist should be considered in these circumstances |
| Cognitive impairment | Patients may have challenges with the self-management activities required to care for the drain and may be at higher risk for damage or dislodgement of the drainage tube |
| Immunosuppressed (i.e. prior organ transplant, immunosuppression, etc.) | May increase the chance of infection |
| Unsafe living environment | Will limit the ability for home care to provide support in the community |
Step 3:
Provide pre-procedure patient counselling:
- Theoretical increased risk of SBP, although in small studies that include prophylactic antibiotics, risk does not appear greater than standard SBP
- Long-term prophylactic antibiotics will be prescribed
- Leakage is the most common complication
- Submersing the drain (bathing or swimming) is not recommended
- IV albumin may still be recommended at times depending on drainage volume and renal function
- Homecare services are required for maintenance of the drain
- Drainage frequency can be adjusted, and some patients may need daily drainages
Step 4:
Arranging IPC placement and follow up care:
- Send referral to interventional radiology for “Abdominal PleurX insertion”.
- Once booking date known, send referral and drain management orders to Community Care Access. Be sure to include:
- Home Care Referral Form
- Patient demographic sheet
- Medication list
- Home Care Management Orders
- Provide patient with prescription for SBP prophylaxis to be started 1 day prior to drain insertion (Norfloxacin 400mg daily, Ciprofloxacin 500mg daily, or Septra DS one tab daily).
- Send Drain Placement Orders to diagnostic imaging recovery area one day prior to insertion date.
- Arrange routine lab work for the patient (lab or home collections). Frequency should be based on patient goals of care and risk of complications.
Management Recommendations:
- Occurs most commonly in the early weeks after the drain is inserted. To manage leaking, until the drain site heals, consider more aggressive ascites drainage +/- albumin replacement (to preserve renal function).
- We recommend against removing the drain site suture until the drain site has healed and leaking stopped.
- Putting a suture to tighten the exit site of the IPC site should be done as well. If ineffective, another option is using medical grade glue applied at the leaking exit site.
- Avoid bagging or placing a fluid collection system around the drain as this may promote infection and shift focus away from healing the drain site.
- Dressings should be changed frequently during periods of leaking so that wet dressings are not sitting against the skin for prolonged periods of time.
- If renal function is declining it is good practice to:
a) evaluate whether diuretics can be reduced and
b) consider reducing total drain volumes or change to more frequent small volume drains
- The decision to give albumin should be based on the patient’s renal function, hemodynamic status, weekly drain volumes and ability to tolerate drain volumes. In general, we recommend albumin 1g/kg in situations such as:
a) stage 1 acute kidney injury
b) symptomatic hypotension, and
c) when drain volume >10L/wk.
- Many patients will require no or minimal albumin, however we recommend patients be monitored for progressive serum albumin depletion and resultant renal dysfunction.
- Albumin does not usually need to be given within a specific time frame following drainage procedures and should instead be arranged in an ambulatory setting where clinically appropriate.
- We recommend routine monitoring for SBP. Home care staff can collect fluid for cell count and differential. Fluid collection for culture and sensitivity is not commonly available in the community.
- If the polymorphonuclear (PMN) count is >250mm/cm3, fluid should be collected for culture and treatment for SBP initiated.
- If the fluid culture is positive with normal cell count (bacteriascites), and the patient is asymptomatic, case-by-case evaluation is required. At a minimum, clinical status, labs, and fluid analysis (cell count and culture) should be repeated within 2-3 days of the initial fluid culture.
- It is not well understood whether an IPC should be remove or left in situ if the patient develops a single episode of SBP. If this situation occurs, case-by-case evaluation is required considering the patient’s goals of care, whether the patient is experiencing recurring infections, and the type of bacteria cultured (common SBP bacteria vs not).
Patients can experience significant pain at the end of the drain procedure when vacuum bottles are used. Most can learn to recognize when they are about to experience pain and clamp the drain prior, however some may require modification (switch to gravity drainage system or adjust the clamp to slow the drainage rate).
- A cellulitis is suggested by the presence of warm, erythematous, and painful skin. If a cellulitis is suspected, a trial of antibiotics for 1 week can be considered. This often is enough to resolve the infection.
- We recommend sending fluid for cell count and differential, and also for bacterial culture to rule out a SBP which would warrant specific antibiotics, and potentially drain removal.
When patients experience skin irritation or a rash around the drain insertion site, modifications to skin cleansing and dressing materials should be considered. Home care can typically make modifications as they see fit.
Recommend more aggressive ascites drainage +/- albumin replacement as tolerated, to reduce risk of rupture.
Episodic blood tinged ascites has been reported and typically resolves spontaneously. Evaluate fluid for infection and assess hemodynamic status.
pleurx.
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