Guidelines
There are no guidelines on how much ascites can be removed and how quickly the ascites can be removed during LVP. The goal of a therapeutic paracentesis is to remove as much fluid as possible, and there are no limits on the amount that can be removed safely.1 Concerning paracentesis flow rates, Elsabaawy and colleagues showed that ascites flow rate does not correlate with PICD. They looked at 3 groups with ascites flow rates of 80 mL/min, 180 mL/min and 270 mL/min.29 We had data on the time in the procedure room in 77% of our procedures. Given our average amount of ascites removed (7.9 L) and average time in the procedure room (33.3 minutes), the average flow rate from our clinic was at least 237 mL/min (although the flow rate was likely higher because the average time from needle inserted to needle removed was < 33.3 minutes). Both the mean duration of LVP and the mean volume of ascites removed in an outpatient paracentesis clinic were reported in only 1 other study. In a study of 1100 patients, Grabau and colleagues reported the mean duration, defined as the time between when the patient entered and exited the procedure room (the same time period we reported) as 97 minutes and the mean volume of ascites removed as 8.7 L.13
The AASLD guidelines state that patients undergoing serial outpatient LVP should be tested only for cell count and differential without sending a bacterial culture. The reason given is that false positives may exceed true positives from ascites bacterial culture results in asymptomatic patients.3 Mohan and Venkataraman reported a 0.4% rate of SBP, 1.4% rate of CNNA, and 0.7% rate of MNB in asymptomatic patients undergoing LVP in an outpatient clinic.30 We had a 0.2% rate of SBP, 0.4% rate of CNNA, and 0.2% rate of MNB. Given the low rates of SBP in outpatient paracenteses clinics, we will adopt the AASLD suggestions to only send an ascites cell count and not a culture in asymptomatic patients. Noteworthy, our patient with asymptomatic SBP grew vancomycin-resistant Enterococcus faecium, which was resistant to standard SBP antibiotic therapy. However, if ascites culture was not sent, he would have been treated with antibiotics for CNNA, and if he developed symptoms, he would have had a repeat paracentesis with cell count and culture sent.
Training
In 2015, faculty at VAPHS and the University of Pittsburgh School of Medicine designed a Mastering Paracentesis for Medical Residents course based on current guidelines on the management of ascites and published procedural guides. The course is mandatory for all postgraduate year-1 internal medicine residents and begins with 2 hours of didactic and simulation-based training with an ultrasound-compatible paracentesis mannequin. In the 3 weeks following simulation-based training, residents rotate through our outpatient paracentesis clinic and perform between 1 and 3 abdominal paracentesis procedures, receiving as-needed coaching and postprocedure feedback from faculty. Since the course’s inception, more than 150 internal medicine residents have been trained in paracentesis through our clinic.
Conclusions
We present a description of a successful outpatient paracentesis clinic at our hospital run by academic hospitalists. The clinic was created to decrease the number of admissions for LVP. We were fortunate to be able to use the GI endoscopy suite and their resources as the clinic setting. To create outpatient LVP clinics at other institutions, administrative support is essential. In conclusion, we have shown that an outpatient paracentesis clinic run by academic hospitalists can safely and quickly remove large volumes of ascites.