Ascites, the build-up of fluid in the abdomen, is common in advanced liver cirrhosis and also occurs in some cancers, heart failure and kidney disease. Large volumes can cause discomfort, breathlessness, reduced appetite and immobility. Abdominal paracentesis drains this fluid, either for diagnosis (a small sample) or for symptom relief (therapeutic or large-volume paracentesis). Nurses prepare the patient, monitor them during drainage, manage the drain and watch for complications.
Types of paracentesis
- Diagnostic paracentesis: a small amount of fluid (for example 20 to 60 mL) is taken to check for infection (spontaneous bacterial peritonitis, SBP), cancer cells or other causes. Every patient with cirrhosis and ascites admitted to hospital usually has a diagnostic tap, because SBP can be present without obvious symptoms.
- Therapeutic (large-volume) paracentesis: several litres are drained to relieve symptoms, usually via a temporary drain over a few hours.
- Long-term indwelling drains: sometimes used in palliative care, particularly for malignant ascites, so fluid can be drained at home.
Before the procedure
- Confirm identity, explain the procedure and ensure consent.
- Record baseline observations: blood pressure, pulse, respiratory rate, oxygen saturation, temperature.
- Weigh the patient and measure abdominal girth at a marked point, to compare after drainage.
- Check recent blood results as requested: full blood count, clotting, kidney function and electrolytes. In cirrhosis, mildly abnormal clotting tests don’t usually prevent paracentesis, but follow local policy.
- Ask the patient to empty their bladder to reduce the risk of bladder injury.
- Make sure albumin is prescribed if a large-volume drain is planned (see below).
- Prepare equipment as per policy. Ultrasound is often used to choose a safe site.
During the procedure
- Position the patient comfortably, usually lying on their back, slightly tilted towards the side of the drain.
- Support the clinician with sterile technique.
- Monitor the patient’s comfort and observations.
- Send samples correctly labelled to the laboratory: typically cell count (neutrophils), culture (often inoculated into blood culture bottles at the bedside), protein or albumin, and cytology if cancer is suspected.
Albumin replacement
Removing large volumes of ascites can cause fluid shifts that lead to low blood pressure and kidney injury, a condition sometimes called post-paracentesis circulatory dysfunction. To reduce this risk, guidelines from bodies such as the British Society of Gastroenterology and the European Association for the Study of the Liver recommend human albumin solution (usually 20% albumin) when more than about 5 litres are drained. A commonly used dose is 8 g of albumin per litre of ascites removed (for example 100 mL of 20% albumin per 2.5 to 3 litres). Follow your local protocol and prescription.
Drain management
- Secure the drain and check it regularly for kinks, leakage and disconnection.
- Record the volume drained hourly on a fluid balance chart.
- Follow local policy on drainage rate and maximum volume. Many units drain over 4 to 6 hours and remove the drain within 6 hours to reduce the risk of infection. Some policies include clamping and releasing the drain; others allow free drainage.
- Give albumin as prescribed during or after drainage.
- Never leave a drain in place longer than the policy allows without medical review.
Monitoring and complications
Monitor observations regularly during drainage and for some hours after, per local policy. Watch for:
- Hypotension and tachycardia: may indicate circulatory dysfunction or bleeding. Slow or stop drainage and escalate.
- Bleeding: from the puncture site or into the abdomen (falling haemoglobin, abdominal pain, shock).
- Persistent leakage of ascitic fluid from the site after drain removal. A stoma bag over the site can collect fluid and protect the skin.
- Infection: fever, abdominal pain or tenderness, confusion. Report promptly, as SBP is serious.
- Bowel or bladder injury: rare, but severe abdominal pain or faecal or bloody drainage needs urgent review.
- Kidney injury: monitor urine output and blood tests.
- Hepatic encephalopathy: new confusion in a patient with cirrhosis.
After drainage
- Remove the drain as per policy and apply a sterile dressing.
- Re-weigh the patient and measure abdominal girth.
- Document volume drained, albumin given, observations and patient comfort.
- Encourage mobilisation when safe.
Long-term management of ascites
Nurses also support patients to manage ascites and reduce the need for repeated drainage:
- Salt restriction: a moderate reduction in salt intake is usually recommended. Teach patients to avoid adding salt and to limit processed and salty foods.
- Diuretics: such as spironolactone and furosemide, with monitoring of weight, kidney function and electrolytes.
- Alcohol cessation where alcohol is the cause of liver disease, with support services.
- Daily weights at home to detect fluid reaccumulation.
- Recognising warning signs: fever, abdominal pain, confusion, vomiting blood or black stools need urgent medical attention.
- Referral to specialist liver services; some patients may be considered for TIPS or liver transplantation.
For patients with advanced disease, discussions about goals of care and palliative support are important, and nurses are often the people patients trust to have these conversations.
Key points
- Every cirrhotic patient admitted with ascites should have a diagnostic tap to exclude SBP.
- Give albumin for large-volume paracentesis as prescribed.
- Monitor observations, drainage volume and the drain site closely.
- Remove drains within the time limit set by policy.
- Teach salt restriction, daily weights and warning signs.