Supra Regional audit on the Management of Ascites · 2016-05-05 · patient with malignant ascites...

Supra Regional audit on

the Management of Ascites

Current Standards and Guidelines- Dawn Gray

Literature Review-Leslie Johnny

Audit data- Ann Griffiths

Revised Standards and Guidelines- Dr Laura Chapman

External Expert- Dr Robert MacDonald

Current Standards 1.

• Patients who have acute symptoms attributable

to ascites should have paracentisis within 48

hours of presentation (Grade D)

• All patients should have baseline U & E prior

and whilst taking diuretic therapy (Grade D)

• I V fluids/ albumin should not be used rountinely

during or following drainage unless in severe

hypovolaemia (Grade D)

Current Standards 2.

• IV fluids /albumin should not be routinely used

during or following paracentesis unless of sever

hypovolaemia (Grade C).

• Abdominal drains should be removed within 24

hours of insertion if there is limited drainage,

unless there is a clinical indication for leaving

them in situ for longer (Grade C).

Current Guidelines - Diuretics Diuretic Therapy should be considered on every

patient with malignant ascites with a prognosis of

greater than 4 weeks. U&E should be checked

prior and during treatment.(pt with liver mets more

likely to respond)

Spironolactone dose range 100-400mg increasing

every 3-7 days by 50-100mg max dose 400mg

Furosemide can be added in if inadequate

response to spiro dose range 40-80mg per day.

Therapeutic Paracentesis

• Insertion of venflon or catheter through the

abdominal wall.

• To control acute symptoms or in those with

diuretic resistance – provides 90% relief.

• Diagnostic imaging is not necessary if on

clinical exam large volume fluid – but may be

required if concerns loculated.

• Consider checking FBC and Clotting if bleeding

or liver mets, U&E if renal impairment

Therapeutic Paracentesis 2

• Obtain and document informed consent.

• Drain fluid as quickly as tolerated by patient,

clamping no necessary.

• Remove drain when no longer in use (infection)

• No supporting evidence of use of albumin

during or after drainage.

• IV fluids not recommended.

• Repeated drainage may be required.

Contra indications to Paracentesis

• Absolute Contra indications – DIC, clinical

evidence of fibrinolysis .

• Relative Contra Indications severe bowel

distension, previous extensive abdo/pelvic

surgery.

Other alternatives.

• Consider Peritoneovenous shunts for those with

prognosis measured in months.

• Denver or Le Veen inserted under LA.

• Octreotide may be useful for chylous ascties

dose range 200-600 mcgs via driver over 24hrs.

• Cytotoxic Therapy may be of benefit if primary

disease breast or ovary as response.

• Intra pertioneal chemo may be of benefit in

some tumour types.

Literature review

Term searched for

Malignant ascites

Palliative care

Thirty-two relevant studies were identified. None were

randomized control trials, one was a non-randomized

open controlled trial, five were cohort studies or

prospective uncontrolled trials, 26 studies were non-

analytic studies like case series.

• Abnormal accumulation of fluid in the peritoneal

cavity as a consequence of cancer.

• Accounts for up to 10% of all cases of ascites (1)

• Common in ovarian, breast, lung and

gastrointestinal malignancies.

• Abdominal pain, discomfort, anorexia, nausea,

dyspnoea, reduced mobility and problems with

body image (2)

Pathophysiology

• Incompletely understood

• In health, there is a constant influx of fluid into the peritoneal cavity which is reabsorbed at a rate of 5- 6mls/hr.

• Combination of fluid over production and impairment in drainage (3)

• Mechanical obstruction due to tumour cells

• Active peptides are produced which increase

the capillary surface area and permeability

• Increase in intraperitoneal protein concentration

and rise in oncotic pressure drawing fluid into

the peritoneal space. (3)

• Circulating blood volume decreases due to

movement of fluid into extra vascular space

there is activation of renin angiotensin

aldosterone axis causing an increase in sodium

retention and exacerbation of fluid

accumulation. (4)

Management

• Several options

• Poor prognostic sign in some cancers-aim of

management is symptomatic

• Frailty and debility may affect management

choice.

• Intervention has to be effective and have a

minimal impact on the QOL

• Survey of 80 physicians working in oncology,

gastroenterology and palliative care carried out

to determine attitudes and preferences. (Lee,

Bociek, Faught 1998)

Diuretics

• Survey in 1998- Half of respondents used diuretics.

• Quarter of those found them to be ineffective method of symptom control.

• Survey in 2005- 48% sometimes and 37% often used diuretics (Newman, Pudney 2005)

• Inconsistency is reflected in the evidence base

• No randomised trials to assess efficacy and no

consensus on effectiveness (Smith et al 2003)

• Observational studies found to be effective in

43% patients. (Becker et al 2006)

• Variety of tumour types and the diuretics used

were spironolactone, frusemide and

bumetanide.

• Serum-ascites albumin gradient (SAAG)>1.1was associated with improved responsiveness.(Pockros, Esrason, Duque, Woods 1992)

• A raised SAAG is seen in patients with large hepatic metastases and portal hypertension.

• Low SAAG seen in patients with peritoneal disease.

• Plasma renin/ aldosterone concentration was raised in patients who responded to spironolactone. (Greenway, Johnson, Williams 1982)

• Useful management strategy- Non invasive and

may suit certain patient groups.

• Recommended starting dose based on limited

evidence would be Spironolactone 150 mg/day

increasing to 400 mg/day.

• Urea& Electrolytes need to be monitored

regularly( Smith et al 2003)

• Removal of fluid from the peritoneal cavity by

catheter drainage.

• Although temporary, effective symptom relief in

90% patients (Parsons, Watson, Steele 1996)

• No consensus on the speed of fluid drainage

(Becker et al 2006)

Difference between Hospital and

Hospice

• In Hospital USG, longer drainage times and concurrent IV fluids.

• Hence longer inpatient stay.

• Stephenson(2002) produced guidelines

Use of USG only in diagnostic uncertainty

Allow 5 litres to drain without clamping

Leave drains no longer than 6 hours.

• Based on these guidelines a case note review

showed reduction in number of USG scans

and the length of time the drains were left in

• Shorter inpatient stays

• No episodes of symptomatic hypotension

• IV fluids were used only on 6 occasions.

• In ascites due to liver cirrhosis use of albumin

and plasma expander have shown to prevent

circulatory dysfunction.

• Lack of study evidence to suggest the use of

albumin in malignant ascites (Gines, Cardenas,

Arroyo 2004)

• Paracentesis although effective only provides

temporary relief of symptoms.

• Study of 67 patients with breast, ovarian and

bowel cancer required 392 paracentesis

averaging 6 procedures/patient. ( Rosenburg

• Mean interval between procedures was 10.4

days.(Becker et al 2006)

Permanent Indwelling Catheters

• Used to prevent recurrent invasive procedures.

• Considered when the frequency of serial

paracentesis is becoming burdensome.

• Two types 1) Secured and tunnelled

2) Non tunnelled

• Reviews of use of permanent drains by Smith et

al (2003) found that in all 56 patients

symptomatic control was achieved.

• Significant risk of infection (38%)

• More recent review reported the median

infection rate to be 5.9%.(Range 2.5- 34%)

• Found un-tunnelled catheters to be most

commonly associated with infections.(Fleming et

al 2009)

Peritoneovenous Shunt

• Permanent connection between peritoneal

cavity and superior vena cava.

• Continuous infusion of fluid via a one way valve

back to superior vena cava.

• Developed for use in ascites due to liver

cirrhosis.

• Have become popular in the management of

malignant ascites( Lee et al 1998)

• Le Veen shunt and Denver shunt

• There maybe a reduction in protein loss

associated with removal of fluid (Gough 1984)

• Estimated to provide symptomatic benefit in

approximately 70% patients( Smith et al 2003)

• Variable response rate

• Gastrointestinal cancers as low as 10-15%

(Adam et al 2004)

• Likely to be due to poor prognosis.

• Best response rates in patients with breast and

ovarian cancers who have a longer life

expectancy.(Adam et al 2004)

• Expected survival time of patient is important

factor when use is considered.

• No consensus about time span in literature.

• Some suggest greater than 1 month some

suggest greater than 3 months.(Becker et al

• Contraindications include

1) Haemorrhagic ascites

2) Protein content greater than 4.5 g/l

3) Loculated ascites

4)Portal Hypertension

5)Coagulation Disorders

6)Advanced renal and cardiac failure

Complications

• DIC

• Pulmonary Oedema

• Dissemination of Cells from peritoneum to

pulmonary vasculature. (Smith et al 2003)

• Patients require monitoring with Central venous

catheter for 24 hours post procedure.

Newer Therapies

• Intra-peritoneal Chemotherapy.

Destruction of cells on the peritoneal surface

and fibrotic reaction is induced which prevents

the production of peritoneal fluid.(Adam et al

• Overall control of ascites achieved in 47%

patients(Smith et al). Patients were also on

systemic chemo.

• Complications similar to paracentesis.

• Intra-peritoneal Hyperthermic chemotherapy.

• Used in trials alone and in combination with

cytoreductive surgery.

• Rates of control of ascites range from 75-100%

in trials. (Chung,Kozuch,2008)

Octreotide

• Case series of 3 patients(Cairns, Malone

• Showed reduction in the need for

paracentesis.

• Postulate that adenocarcinomas are likely to

respond better.

• Phase 3, randomised, double blind, placebo

controlled, multicentre study in progress

(National cancer Institute 2009)

Monoclonal Antibodies

• Catumaxomab in hepatobiliary and colonic

carcinomas (Chung et al 2008)

• Burges et al 2007- 95% response rate in 23

patients with ovarian cancer eliminating the

need for paracentesis 37 days after the infusion.

• Parsons et al 2007-Another study with 129

ovarian cancer patients.

• Anti-VEGF monoclonal antibody under testing

(Chung et al 2008)

• Cochrane Review 2010 for malignant ascites

in Gynaecological cancer- Was unable to

make any recommendations due to lack of

multicentre RCT.

• Ultrasound should always be used for:

– First diagnosis of Ascites

– Suspected loculated ascitic fluid

– Bleeding diathesis

– Guage the distance from skin to fluid, and from fluid to

bowel.

– Suspected hepatosplenomegaly

• Ultrasound works best when it is performed by the same

person who will be performing the procedure. If getting a

formal US to document ascites and to mark for

paracentesis, you should be present in radiology to

witness the patient positioning during the US marking.

Palliative Ultrasound for Home Care Hospice

Patients

Peter J. Mariani, MD, and Judith A. Setla, MD,

ACADEMIC EMERGENCY MEDICINE 2010;

17:293–296 ª 2010 by the Society for Academic

Emergency Medicine

EUROPEAN JOURNAL OF

PALLIATIVE CARE, 2009; 16(5)

•Using ultrasound in hospices

•Doctors at Willen Hospice in Milton Keynes were

trained to identify abdominal ascites using

ultrasound, thus avoiding having to send patients

to hospital for the procedure.

• Amy E H Kingston and John Moyle report on a

small retrospective study to evaluate the change

• BMJ Support Palliat Care 2011;1:224

doi:10.1136/bmjspcare-2011-000105.60

• Poster presentations

• Ultrasound scanning in a hospice setting –

does it really alter patient pathways?

• Erzsi Nemeth, Woodwark Cate, Chadwick

Sharon

• Bedside scans prevent distressing transfer to

hospital and unnecessary procedures when time is

short. Patients feel this imaging is neither intrusive

nor distressing.

• Conclusion Bedside ultrasounds are non-invasive

and well tolerated, aiding diagnosis, safety and

outcomes for patients with suspected ascites or

bladder problems.

• Focused abdominal Sonography in Palliative care

(FASP)

Audit Data

• General Questionnaire via Survey monkey

• Paracentesis Questionnaire - Distributed to all

specialist palliative care teams and units via the

• 6 month duration

Health Care Professional

Setting Of ICN

How do you routinely confirm ascites?

What percentage of patients with ascites have ultrasound for

paracentesis?

Where would you routinely refer a patient for paracentesis?

Do you have access to units where permanent indwelling

catheters are inserted for the management of recurrent

ascites?

Do you have patient information leaflets regarding ascites

and paracentesis?

Does your unit offer open access service for the drainage of

ascites?

If you work in a specialist unit does your unit have a hand

held scanning device?

Paracentesis

Questionnaire

Completed Questionnaire per ICN and Setting

Hospice Hospital Community

Patient Profile

41-50 51-60 61-70 71-80 >80 NotRecorded

Age Range

Male Female Not Recorded

Primary Disease

4% 5%1%

4%1%3%

1%3% 3%3%

10%15%20%25%30%35%40%45%

Ovarian

Primary Disease

Source of referral

Source Number Percentage

Community 9 12

Hospital 31 42

Self referral 26 35

Other Units 3 4

Not Recorded 5 7

Total 74 100

Diagnosis of Ascites

ClinicalExamination

Radiology

Unknown

Symptoms attributed to Ascites prior to drainage

Fatigue

bility

Symptoms

Diuretic Treatment

18% 18%

Spironolocatone Furosemide Both Other Not Recorded

Were the U&Es checked before starting Diuretics?

Yes No Not Known Not Recorded

Did the patient proceed to paracentesis?

Yes No

Day case

Yes No

Blood tests prior to Paracentesis

Of the 34 patients were bloods were recorded, the following were taken:

Bloods Performed

Consent

Written Verbal Not Recorded

Volume of equipment used

Bonnano

Catheter

IV Cannulae

Permanent

Indwelling

Catheter

Recorded

Method of Insertion

Volume of fluid drained

0-6 Hours 6-12

Hours 72

< = 3 L 9 1 - - - -

>3-5 L 21 - 1 1 1 -

>5-7 L 8 4 3 1 - -

>7-10 L - 1 4 2 - 1

Recorded

2 - 1 - - 1

Total 40 6 9 4 1 1

Complications post procedure

Hypotension

Pain/Discomfort

Blocked Drain

Symptoms post procedure

1 1111

3 2 12222

/Disco

bility

Fatigue

Time from admission to procedure

<=24 hours >24 <=48 hours >48 hours Not Recorded

Time from procedure to discharge

<=24 hours >24 <=48 hours >48 hours Patient not discharged Patient Died Not Recorded

Revised Standards &

Guidelines

Dr Laura Chapman

Guidelines (1)

Diuretic therapy • Diuretics should be considered in every

patient with malignant ascites

• U&E checked prior to starting and during

treatment every fortnight

• Spironolactone is diuretic of choice in

malignant ascites

• Patients are unlikely to respond if

serum:ascites albumin gradient is < 1.1

Guidelines (2)

Diuretic therapy

• Patients with raised plasma renin and

massive liver mets most likely to respond

• 100 - 400mg/day, titrate every 3-7 days

• Furosemide (loop diuretic) added if

inadequate response to spironolactone

• Dose 40-80mg/day

• Side effects of both: electrolyte imbalance,

hypotension and gastrointestinal disturbance

Guidelines (3)

Therapeutic Paracentesis • Paracentesis is useful in the control of acute

symptoms, or in those patients resistant to diuretics

• Can be performed in the IP and OP setting, ideally within 48 hours of presentation

• Diagnostic imaging is not required if clinical examination demonstrates large volume ascites

• USS evaluation may be required if loculation or peritoneal disease is suspected

Guidelines (4)

• Ideally if USS is required, the drain should be inserted at the same time

• Consider checking FBC & clotting if patient has risk of bleeding. U&E if renal impairment

• Gain informed consent and record in casenotes

• Fluid should be drained as quickly as is comfortable

• Before procedure, empty bladder and use analgesia as required

• Drains should be removed when no longer in use

• No evidence to support use of IV infusions

• Repeated paracentesis may be required

• Contraindications - absolute: DIC; relative: bowel distension, previous abdo surgery

Guidelines (5)

Peritoneovenous shunts

• Drains ascitic fluid from peritoneal space to the internal jugular vein

• May limit the need for diuretics +/or paracentesis if prognosis is months rather than weeks

• Can be inserted under LA

• Complications include sepsis, leakage, thromboembolism, GI bleed, blockage, pulmonary oedema

Guidelines (6)

Permanent indwelling catheters

• Permanent indwelling catheters should be considered for patients:

– Requiring repeated regular paracentesis

– More appropriate for certain tumour types

– When not receiving chemotherapy due to infection risk

– Longer prognosis - weeks to months

Guidelines (7)

• Octreotide: useful in chylous ascites, at 200-600 microgrammes/24 hours via CSCI

• Cytotoxic therapy: of benefit if primary disease known to be responsive. Intraperitoneal therapy is of limited use

Standards

• Patients who have symptoms due to ascites

should have paracentesis within 48 hours

• All patients should have baseline U&E

checked prior to commencing and whilst

taking diuretics

• IV infusions (inc. albumin) should not be used

routinely during or after paracentesis - may be

appropriate if severe hypovolaemia

• Drains should be removed within 24 hours if

limited drainage unless clinically indicated.

Comment and discussion

Mr Robert MacDonald

Key points for discussion

• Should patients undergo USS prior to

paracentesis?

• Should hospices have their own ultrasound

scanner?

• Should we be siting more permanent drains?

• Are we using diuretics appropriately?

• Should all patients have an assessment of

plasma renin & aldosterone levels or

serum:ascites albumin gradient?

Supra Regional audit on the Management of Ascites · 2016-05-05 · patient with malignant ascites...

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