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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)
Therapeutic Paracentesis
• 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
situ.
• 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
2004)
• 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
2006)
• 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
2004)
• 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
1999)
• 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,
MPH
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
ICN
• 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
1% 1%
7%
1%
39%
1%
12%
1%
16%
4%1%
11%
3%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Ain
tree
Ha
lton
La
nc
aste
r
Liv
erp
oo
l
St H
ele
ns &
Kn
ow
sley
So
uth
po
rt
We
st
Ch
esh
ire
Wirra
l
No
t
Re
co
rde
d
Hospice Hospital Community
Patient Profile
1%
7% 8%
3%
8%
22%
1%
8%
35%
1%4%
1%0%
5%
10%
15%
20%
25%
30%
35%
41-50 51-60 61-70 71-80 >80 NotRecorded
Age Range
Male Female Not Recorded
Primary Disease
4%
15%
4% 5%1%
11%
1% 1%
39%
4%1%3%
1%3% 3%3%
0%5%
10%15%20%25%30%35%40%45%
Bre
ast
Bile
Du
ct
Ce
rvix
End
om
etriu
m
GI
He
art
Kid
ne
y
Liver
Lymp
ho
ma
Oe
sop
hagu
s
Ovarian
Pan
creas
Pe
riton
eu
m
Stom
ach
Un
kno
wn
No
t Re
cord
ed
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
Both
Unknown
Symptoms attributed to Ascites prior to drainage
313
60
19 18
5810
1718
41
1919
0
10
20
30
40
50
60
70
Ab
do
min
al
Disco
mfo
rt
Diste
nsio
n
Fatigue
An
ore
xia
Re
du
ced
Mo
bility
Dysp
no
ea
Nau
sea
Pain
An
kle
Od
em
a
Vo
mitin
g
Inso
mn
ia
Re
flux
Hicco
ugh
Oth
er
Symptoms
Diuretic Treatment
49%
18% 18%
2%
13%
Spironolocatone Furosemide Both Other Not Recorded
Were the U&Es checked before starting Diuretics?
33%
7%
36%
24%
Yes No Not Known Not Recorded
Did the patient proceed to paracentesis?
82%
18%
Yes No
Day case
41%
59%
Yes No
Blood tests prior to Paracentesis
Of the 34 patients were bloods were recorded, the following were taken:
28
2
32
1816
0
5
10
15
20
25
30
35
FBC
U&
E
INR
LFT
AP
TT
Bloods Performed
Consent
25%
73%
2%
Written Verbal Not Recorded
Volume of equipment used
59%
25%
11%
3%2%
0%
10%
20%
30%
40%
50%
60%
Bonnano
Catheter
IV Cannulae
Permanent
Indwelling
Catheter
Other
Not
Recorded
Method of Insertion
36%
54%
10%
0%
10%
20%
30%
40%
50%
60%
Clin
ical
Asse
ssme
nt
Dire
ct
Ima
gin
g
Dra
ina
ge
Site
ma
rke
d
by
U/S
Volume of fluid drained
0-6 Hours 6-12
Hours
12-24
Hours
24-48
Hours
48-72
Hours 72
Hours
< = 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
Not
Recorded
2 - 1 - - 1
Total 40 6 9 4 1 1
Complications post procedure
Hypotension
Pain/Discomfort
Blocked Drain
Symptoms post procedure
1 1111
27
3 2 12222
15
33
0
5
10
15
20
25
30
Pain
/Disco
mfo
rt
Diste
nsio
n
Nau
sea
Bre
athle
ssne
ss
Ye
s
Mo
bility
Ap
pe
tite
Inso
mn
ia
Dysp
no
ea
An
ore
xia
Fatigue
Blo
ating
Fulln
ess
Re
flux
Vo
mitin
g
Co
nstip
ation
Time from admission to procedure
58%
2%25%
15%
<=24 hours >24 <=48 hours >48 hours Not Recorded
Time from procedure to discharge
55%
5%20%
5%
5%
10%
<=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
77
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
77
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)
Therapeutic Paracentesis
• 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?
