Effects of paracentesis on hemodynamic parameters and respiratory function in critically ill patients

BMC Gastroenterology

Wolfgang Huber²  Roland M Schmid²  Ulrich Mayr²  Philipp Thies²  Caroline Schultheiß²  Alexander Hapfelmeier¹  Christina Ernesti²  Bernd Saugel²  Veit Phillip² 

[1] Institut für Medizinische Statistik und Epidemiologie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675 München, Germany;II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675 München, Germany

关键词: Hemodynamic monitoring;    Transpulmonary thermodilution;    Hemodynamics;    Dynamic respiratory system compliance;    Ascites;   

Others  :  855734
DOI  :  10.1186/1471-230X-14-18

 received in 2013-10-11, accepted in 2014-01-25,  发布年份 2014

【 摘 要 】

Background

Ascites is a major and common complication of liver cirrhosis. Large or refractory ascites frequently necessitates paracentesis. The aim of our study was to investigate the effects of paracentesis on hemodynamic and respiratory parameters in critically ill patients.

Methods

Observational study comparing hemodynamic and respiratory parameters before and after paracentesis in 50 critically ill patients with advanced hemodynamic monitoring. 28/50 (56%) required mechanical ventilation.

Descriptive statistics are presented as mean ± standard deviation for normally distributed data and median, range, and interquartile range (IQR) for non-normally distributed data. Comparisons of hemodynamic and respiratory parameters before and after paracentesis were performed by Wilcoxon signed-rank tests. Bivariate relations were assessed by Spearman’s correlation coefficient and univariate regression analyses.

Results

Median amount of ascites removed was 5.99 L (IQR, 3.33-7.68 L). There were no statistically significant changes in hemodynamic parameters except a decrease in mean arterial pressure (-7 mm Hg; p = 0.041) and in systemic vascular resistance index (-116 dyne·sec/cm⁵/m²; p = 0.016) when measured 2 hours after paracentesis. In all patients, oxygenation ratio (PaO₂/FiO₂; median, 220 mmHg; IQR, 161–329 mmHg) increased significantly when measured immediately (+58 mmHg; p = 0.001), 2 hours (+9 mmHg; p = 0.004), and 6 hours (+6 mmHg); p = 0.050) after paracentesis. In mechanically ventilated patients, lung injury score (cumulative points without x-ray; median, 6; IQR, 4–7) significantly improved immediately (5; IQR, 4–6; p < 0.001), 2 hours (5; IQR, 4–7; p = 0.003), and 6 hours (6; IQR 4–6; p = 0.012) after paracentesis.

Conclusion

Paracentesis in critically ill patients is safe regarding circulatory function and is related to immediate and sustained improvement of respiratory function.

【 授权许可】

   
2014 Phillip et al.; licensee BioMed Central Ltd.

【 参考文献 】

• [1]Gines P, Quintero E, Arroyo V, Teres J, Bruguera M, Rimola A, Caballeria J, Rodes J, Rozman C: Compensated cirrhosis: natural history and prognostic factors. Hepatology 1987, 7:122-128.
• [2]Kim WR: The burden of hepatitis C in the United States. Hepatology 2002, 36:S30-S34.
• [3]Powell WJ Jr, Klatskin G: Duration of survival in patients with Laennec’s cirrhosis. Influence of alcohol withdrawal, and possible effects of recent changes in general management of the disease. Am J Med 1968, 44:406-420.
• [4]D’Amico G, Morabito A, Pagliaro L, Marubini E: Survival and prognostic indicators in compensated and decompensated cirrhosis. Dig Dis Sci 1986, 31:468-475.
• [5]Llach J, Gines P, Arroyo V, Rimola A, Tito L, Badalamenti S, Jimenez W, Gaya J, Rivera F, Rodes J: Prognostic value of arterial pressure, endogenous vasoactive systems, and renal function in cirrhotic patients admitted to the hospital for the treatment of ascites. Gastroenterology 1988, 94:482-487.
• [6]Moore KP, Wong F, Gines P, Bernardi M, Ochs A, Salerno F, Angeli P, Porayko M, Moreau R, Garcia-Tsao G, Jimenez W, Planas R, Arroyo V: The management of ascites in cirrhosis: report on the consensus conference of the International Ascites Club. Hepatology 2003, 38:258-266.
• [7]Moore KP, Aithal GP: Guidelines on the management of ascites in cirrhosis. Gut 2006, 55(Suppl 6):vi1-vi12.
• [8]Runyon BA: Paracentesis of ascitic fluid. A safe procedure. Arch Intern Med 1986, 146:2259-2261.
• [9]Ruiz-del-Arbol L, Monescillo A, Jimenez W, Garcia-Plaza A, Arroyo V, Rodes J: Paracentesis-induced circulatory dysfunction: mechanism and effect on hepatic hemodynamics in cirrhosis. Gastroenterology 1997, 113:579-586.
• [10]Nasr G, Hassan A, Ahmed S, Serwah A: Predictors of large volume paracantesis induced circulatory dysfunction in patients with massive hepatic ascites. J Cardiovasc Dis Res 2010, 1:136-144.
• [11]Peltekian KM, Wong F, Liu PP, Logan AG, Sherman M, Blendis LM: Cardiovascular, renal, and neurohumoral responses to single large-volume paracentesis in patients with cirrhosis and diuretic-resistant ascites. Am J Gastroenterol 1997, 92:394-399.
• [12]Quintero E, Gines P, Arroyo V, Rimola A, Bory F, Planas R, Viver J, Cabrera J, Rodes J: Paracentesis versus diuretics in the treatment of cirrhotics with tense ascites. Lancet 1985, 1:611-612.
• [13]Gines P, Arroyo V, Quintero E, Planas R, Bory F, Cabrera J, Rimola A, Viver J, Camps J, Jimenez W: Comparison of paracentesis and diuretics in the treatment of cirrhotics with tense ascites. Results of a randomized study. Gastroenterology 1987, 93:234-241.
• [14]Malbrain ML, Chiumello D, Pelosi P, Bihari D, Innes R, Ranieri VM, Del Turco M, Wilmer A, Brienza N, Malcangi V, Cohen J, Japiassu A, De Keulenaer BL, Daelemans R, Jacquet L, Laterre PF, Frank G, de Souza P, Cesana B, Gattinoni L: Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: a multiple-center epidemiological study. Crit Care Med 2005, 33:315-322.
• [15]Rouby JJ, Constantin JM, Roberto De AGC, Zhang M, Lu Q: Mechanical ventilation in patients with acute respiratory distress syndrome. Anesthesiology 2004, 101:228-234.
• [16]Chao Y, Wang SS, Lee SD, Shiao GM, Chang HI, Chang SC: Effect of large-volume paracentesis on pulmonary function in patients with cirrhosis and tense ascites. J Hepatol 1994, 20:101-105.
• [17]Angueira CE, Kadakia SC: Effects of large-volume paracentesis on pulmonary function in patients with tense cirrhotic ascites. Hepatology 1994, 20:825-828.
• [18]Byrd RP Jr, Roy TM, Simons M: Improvement in oxygenation after large volume paracentesis. South Med J 1996, 89:689-692.
• [19]Duranti R, Laffi G, Misuri G, Riccardi D, Gorini M, Foschi M, Iandelli I, Mazzanti R, Mancini M, Scano G, Gentilini P: Respiratory mechanics in patients with tense cirrhotic ascites. Eur Respir J 1997, 10:1622-1630.
• [20]Lalrothuama GD, Agrawal PN, Aggarwal AN, Dhiman RK, Behera D, Chawla Y: Pulmonary function changes after large volume paracentesis. Trop Gastroenterol 2000, 21:68-70.
• [21]Levesque E, Hoti E, Jiabin J, Dellamonica J, Ichai P, Saliba F, Azoulay D, Samuel D: Respiratory impact of paracentesis in cirrhotic patients with acute lung injury. J Crit Care 2011, 26:257-261.
• [22]Saugel B, Ringmaier S, Holzapfel K, Schuster T, Phillip V, Schmid RM, Huber W: Physical examination, central venous pressure, and chest radiography for the prediction of transpulmonary thermodilution-derived hemodynamic parameters in critically ill patients: a prospective trial. J Crit Care 2011, 26:402-410.
• [23]Gruenewald M, Renner J, Meybohm P, Hocker J, Scholz J, Bein B: Reliability of continuous cardiac output measurement during intra-abdominal hypertension relies on repeated calibrations: an experimental animal study. Crit Care 2008, 12:R132. BioMed Central Full Text
• [24]Murray JF, Matthay MA, Luce JM, Flick MR: An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis 1988, 138:720-723.
• [25]El-Khatib MF, Jamaleddine GW: A new oxygenation index for reflecting intrapulmonary shunting in patients undergoing open-heart surgery. Chest 2004, 125:592-596.
• [26]Cruz DN, Antonelli M, Fumagalli R, Foltran F, Brienza N, Donati A, Malcangi V, Petrini F, Volta G, Bobbio Pallavicini FM, Rottoli F, Giunta F, Ronco C: Early use of polymyxin B hemoperfusion in abdominal septic shock: the EUPHAS randomized controlled trial. JAMA 2009, 301:2445-2452.
• [27]Zuppa AF, Nadkarni V, Davis L, Adamson PC, Helfaer MA, Elliott MR, Abrams J, Durbin D: The effect of a thyroid hormone infusion on vasopressor support in critically ill children with cessation of neurologic function. Crit Care Med 2004, 32:2318-2322.
• [28]Umgelter A, Reindl W, Wagner KS, Franzen M, Stock K, Schmid RM, Huber W: Effects of plasma expansion with albumin and paracentesis on haemodynamics and kidney function in critically ill cirrhotic patients with tense ascites and hepatorenal syndrome: a prospective uncontrolled trial. Crit Care 2008, 12:R4. BioMed Central Full Text
• [29]Saugel B, Phillip V, Ernesti C, Messer M, Meidert AS, Schmid RM, Huber W: Impact of large-volume thoracentesis on transpulmonary thermodilution-derived extravascular lung water in medical intensive care unit patients. Care J Crit Care 2013, 28:196-201.
• [30]Sakka SG, Ruhl CC, Pfeiffer UJ, Beale R, McLuckie A, Reinhart K, Meier-Hellmann A: Assessment of cardiac preload and extravascular lung water by single transpulmonary thermodilution. Intensive Care Med 2000, 26:180-187.
• [31]Gines A, Fernandez-Esparrach G, Monescillo A, Vila C, Domenech E, Abecasis R, Angeli P, Ruiz-Del-Arbol L, Planas R, Sola R, Gines P, Terg R, Inglada L, Vaque P, Salerno F, Vargas V, Clemente G, Quer JC, Jimenez W, Arroyo V, Rodes J: Randomized trial comparing albumin, dextran 70, and polygeline in cirrhotic patients with ascites treated by paracentesis. Gastroenterology 1996, 111:1002-1010.
• [32]Schrier RW, Arroyo V, Bernardi M, Epstein M, Henriksen JH, Rodes J: Peripheral arterial vasodilation hypothesis: a proposal for the initiation of renal sodium and water retention in cirrhosis. Hepatology 1988, 8:1151-1157.
• [33]Bernardi M, Caraceni P, Navickis RJ, Wilkes MM: Albumin infusion in patients undergoing large-volume paracentesis: a meta-analysis of randomized trials. Hepatology 2012, 55:1172-1181.
• [34]Umgelter A, Wagner K, Reindl W, Nurtsch N, Huber W, Schmid RM: Haemodynamic effects of plasma-expansion with hyperoncotic albumin in cirrhotic patients with renal failure: a prospective interventional study. BMC Gastroenterol 2008, 8:39. BioMed Central Full Text
• [35]Salerno F, Guevara M, Bernardi M, Moreau R, Wong F, Angeli P, Garcia-Tsao G, Lee SS: Refractory ascites: pathogenesis, definition and therapy of a severe complication in patients with cirrhosis. Liver Int 2010, 30:937-947.
• [36]Runyon BA: Management of adult patients with ascites due to cirrhosis: an update. Hepatology 2009, 49:2087-2107.
• [37]Runyon BA: Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis. Hepatology 2012, 57:1651-1653.
• [38]McCormick P, Mistry P, Kaye G, Burroughs A, McIntyre N: Intravenous albumin infusion is an effective therapy for hyponatraemia in cirrhotic patients with ascites. Gut 1990, 31:204-207.
• [39]Jalan R, Mookerjee R, Cheshire L, Williams R, Davies N: Albumin infusion for severe hyponatremia in patients with refractory ascites: a randomized clinical trial. J Hepatol 2007, 46:S95.
• [40]Sola E, Gines P: Renal and circulatory dysfunction in cirrhosis: current management and future perspectives. J Hepatol 2010, 53:1135-1145.
• [41]Pozzi M, Osculati G, Boari G, Serboli P, Colombo P, Lambrughi C, De Ceglia S, Roffi L, Piperno A, Cusa EN: Time course of circulatory and humoral effects of rapid total paracentesis in cirrhotic patients with tense, refractory ascites. Gastroenterology 1994, 106:709-719.
• [42]Panos MZ, Moore K, Vlavianos P, Chambers JB, Anderson JV, Gimson AE, Slater JD, Rees LH, Westaby D, Williams R: Single, total paracentesis for tense ascites: sequential hemodynamic changes and right atrial size. Hepatology 1990, 11:662-667.
• [43]Umgelter A, Wagner KS, Reindl W, Luppa PB, Geisler F, Huber W, Schmid RM: Renal and circulatory effects of large volume plasma expansion in patients with hepatorenal syndrome type 1. Ann Hepatol 2012, 11:232-239.
• [44]Cabrera J, Falcon L, Gorriz E, Pardo MD, Granados R, Quinones A, Maynar M: Abdominal decompression plays a major role in early postparacentesis haemodynamic changes in cirrhotic patients with tense ascites. Gut 2001, 48:384-389.
• [45]Guazzi M, Polese A, Magrini F, Fiorentini C, Olivari MT: Negative influences of ascites on the cardiac function of cirrhotic patients. Am J Med 1975, 59:165-170.
• [46]Wauters J, Claus P, Brosens N, McLaughlin M, Hermans G, Malbrain M, Wilmer A: Relationship between abdominal pressure, pulmonary compliance, and cardiac preload in a porcine model. Crit Care Res Pract 2012, 2012:763181.
• [47]Wang HYAF, Yang XY, Yang XF, Ran XG: Clinical outcome after pressure reduction by peritoneal catheterization in 29 patients with malignant ascites-induced abdominal compartment syndrome. Zhonghua Wei Chang Wai Ke Za Zhi 2010, 13:273-275.
• [48]Mohmand H, Goldfarb S: Renal dysfunction associated with intra-abdominal hypertension and the abdominal compartment syndrome. J Am Soc Nephrol 2011, 22:615-621.