Indwelling Pleural Catheters (IPCs) for Refractory Hepatic Hydrothorax

In patients with refractory hepatic hydrothorax, therapeutic options may be limited. Patients often require frequent thoracentesis.  

 

Although Indwelling pleural catheters (IPC) are typically used in malignant pleural effusions, they can be considered in patients with hydrothorax related to cirrhosis. 

Placement is generally ordered after consultation with a liver ± pulmonary specialists, weighing the risks vs benefits.

Step 1:

Evaluate whether the patient is a candidate for other standard of care therapies:

 

  • TIPS 
  • Liver transplant

In the setting of malignant effusions, chemical pleurodesis may be a reasonable option. With a cirrhosis related hydrothorax, pleurodesis is not generally recommended. If it is considered, it should be done only after multidisciplinary discussion involving a liver specialist, pulmonary and interventional radiology.

Step 2: 

Consider potential contraindications to IPC placement:

ContraindicationsRationale
Cognitive impairmentPatients 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 environmentWill limit the ability for home care to provide support in the community

Step 3: 

Provide pre-procedure patient counselling:

  • Risk of infection
  • 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:

Arrange IPC placement and follow up care:

Edmonton

 

  • Option 1: Send a referral to the Chest Medicine Clinic at the Royal Alexandra hospital (fax # 780-735-397).  Follow up and management of complications is done through the clinic.  

 

  • Option 2: Send a referral to Interventional radiology.  Send referral to interventional radiology for “Chest PleurX insertion”.
    1. Once booking date known, send referral and drain management orders to Community Care Access. Be sure to include: 
      1. Home Care Referral form
      2. Patient demographic sheet
      3. Medication list
      4. Homecare Management Order
    2. 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). 
    3. Arrange post insertion routine lab work for the patient (lab or home collections). The frequency should be individualized based on patient goals of care and risk of complications. 

Management Recommendations:

Drain Site Leaking
  • Occurs most commonly in the early weeks after the drain is inserted. To manage leaking, until the drain site heals, consider more aggressive (e.g. daily) pleural fluid drainage +/- albumin replacement (to preserve renal function).
  • Place a suture to tighten the exit site of the IPC site.  If ineffective, another option is medical grade glue applied at the leaking exit site.  
  • Change dressings more frequently during periods of leaking so that wet dressings are not sitting against the skin for prolonged periods of time.
Renal dysfunction & albumin replacement
  • If renal function is declining: 

           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. 
Parapneumonic infection
  • If the fluid culture is positive or is neutrophilic (>50% neutrophils), then a parapneumonic effusion is suspected. Antibiotics are indicated (generally for at least 4 weeks although will vary from case to case).
  • As there no guidelines to standardize management, consider Infectious diseases and Pulmonary consultation to determine the duration of antibiotics, required follow-up to monitor clinic response and whether the tube should be removed.
Skin Cellulitis
  • A cellulitis is suggested by the presence of warm, erythematous, and painful skin.  If cellulitis is suspected, a 1 week antibiotic trial can be considered.  This is often enough to resolve the infection. 
  • If cellulitis is suspected, send the pleural fluid for cell count and differential, and also for bacterial culture to rule out a parapneumonic infection which would warrant a change in management.
Pain during vacuum drainage
  • Patients can experience significant pain at the end of the drain procedure when vacuum bottles are used. 
  • Most patients can learn to recognize when they are about to experience pain and can clamp the drain prior to pain occuring. 
  • The drainage rate can be slowed to reduce the pain as well.
Skin Irritation
  • When patients experience skin irritation or a rash around the drain insertion site, as per standard Home care practice, skin cleansing practices and dressing changes can be modified.

Downloadable content:

You can download these to print or view offline:

Community Care Access

Home Care Referral Form

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