An Academic Hospitalist–Run Outpatient Paracentesis Clinic
Background: Patients needing large-volume paracenteses (LVPs) can occupy inpatient hospital beds and unnecessarily use inpatient resources.
Methods: We describe an outpatient paracentesis clinic that was part of a quality assurance initiative at the Veterans Affairs Pittsburgh Healthcare System in Pennsylvania. A retrospective review was conducted that included patient age, sex, etiology of ascites, amount of ascites removed, time of the procedure, complications, and results of ascites cell count and cultures abstracted from the electronic health record.
Results: Over 74 months, 506 paracenteses were performed on 82 patients. The mean volume removed was 7.9 L, and the mean time of the procedure was 33.3 minutes. There were 5 episodes of postprocedure hypotension that required admission for 3 patients. One episode of abdominal wall hematoma occurred that required admission. Two patients developed incarceration of an umbilical hernia after the paracentesis; both required surgical repair. Without the clinic, almost all the 506 outpatient LVPs we performed would have resulted in a hospital admission.
Conclusion: An outpatient paracentesis clinic run by academic hospitalists can safely and quickly remove large volumes of ascites and minimize hospitalizations.
Results
Between March 2014 and May 2020, 506 paracenteses were performed on 82 patients. The mean age was 66.4 years, and 80 of 82 patients were male. The etiology of the ascites is presented in the Table. Twelve percent of the patients had concomitant hepatocellular carcinoma. Data on the amount of ascites removed were available for all patients, but data on the amount of time it took to do the LVP were available for 392 of 506 paracenteses. The mean volume removed was 7.9 L (range, 0.2-22.9 L), and the mean time of the procedure was 33.3 minutes. The time of the procedure was the time difference between entering and leaving the procedure room. This does not include IV placement or the recovery area time.
There were 5 episodes of postprocedure hypotension that required IV fluid or admission. In all these events, the patients had received the appropriate amount of IV albumin. Three patients required admission, and 1 patient required IV fluid postparacentesis on 2 occasions and then was discharged home. One abdominal wall hematoma occurred. Two patients with umbilical hernias developed incarceration after the paracentesis; both required surgical repair. There were 3 episodes of leakage at the paracentesis site; a skin adhesive was used in 2 cases, and sutures were applied in the other. There were no deaths.
Possible Infections
Ascitic fluid infection is a risk for patients needing paracentesis. Spontaneous bacterial peritonitis (SBP) is a bacterial infection of ascites in the absence of a focal contiguous source. The polymorphonuclear leukocyte (PMN) count in the ascites is ≥ 250 cells/mm3 in the presence of a single organism on culture. Culture-negative neutrocytic ascites (CNNA) is an ascitic fluid PMN count ≥ 250 cells/mm3 in the absence of culture growth obtained before the administration of antibiotics. Monomicrobial nonneutrocytic bacterascites (MNB) is an ascitic fluid PMN count < 250 cells/mm3 with growth of a single organism on culture.17 There was one occasion where a patient developed symptomatic CNNA 3 days after having a therapeutic paracentesis in the clinic at which time his ascites had a normal neutrophil count and a negative culture. He presented with abdominal pain and fever 3 days later, and a diagnostic paracentesis was done in the ED. He was treated as though he had SBP and did well.
Ascites cell count and culture are routinely sent in the clinic, and 1 case of asymptomatic SBP and 3 cases of asymptomatic ascitic fluid infection variants were diagnosed. The patient with SBP grew vancomycin-resistant Enterococcus faecium in his ascites. Two cases were CNNA. These patients were admitted to the hospital and treated with IV antibiotics. One case of MNB occurred that grew Escherichia coli. The patient refused to return to the hospital for IV antibiotics and was treated with a 5-day course of oral ciprofloxacin.
Discussion
We describe an academic hospitalist–run outpatient LVP clinic where large volumes of ascites are removed efficiently and safely. The only other description of a hospitalist-run paracentesis clinic was in abstract form.16 Without the clinic, the patients would have been admitted to the hospital to get an LVP. Based on VAPHS data from fiscal year 2021, the average cost per day of a nontelemetry medicine admission was $3394. Over 74 months, 506 admissions were prevented, which averages to 82 admissions prevented per year, an approximate annual cost savings of $278,308 in the last fiscal year alone.
