Standardizing the Use of Albumin in Large Volume Paracentesis

Abstract

<jats:sec><jats:title>Background</jats:title><jats:p> Albumin after large volume paracentesis (LVP) reduces paracentesis-induced circulatory dysfunction (PICD). The most efficacious dose of albumin for LVP is unclear. </jats:p></jats:sec><jats:sec><jats:title>Objective</jats:title><jats:p> To evaluate the impact of implementing a standardized LVP order set on albumin utilization and patient outcomes. </jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p> This is a retrospective review of patients with ascites due to cirrhosis who received a therapeutic paracentesis at a large, academic institution. Primary outcome was amount of albumin used prior to and after order set implementation. Albumin doses were standardized in the order set to 25 g (5-6 L removed), 50 g (7-10 L), and 75 g (&gt;10 L). Patient outcomes were rates of hyponatremia, renal impairment, and hypotension. </jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p> There were 100 patients included in each arm of the final analysis. Patients prior to order set implementation received a higher amount of albumin per liter removed compared to those post-implementation (8.3 g/L vs 6.5 g/L, respectively; P &lt; .01). There were no significant differences between groups in absolute changes in serum sodium (0 mEq/L vs −1 mEq/L, P = .64), serum creatinine (0.06 mg/dL vs 0.05 mg/dL, P = .94), or systolic blood pressure (−4 mm Hg vs −3 mm Hg, P = .96). There were no differences between groups in rates of hyponatremia (1.6% vs 6.6%, P = .21), renal impairment (11.3% vs 11.5%, P = .97), or hypotension (17.4% vs 17.6%, P = .97). </jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p> Use of an order set to guide albumin dosing based on amount of ascitic fluid removed during LVP resulted in a significant reduction in the amount of albumin given with no difference in adverse effects. </jats:p></jats:sec>

HEP-Net opinion on the management of ascites and its complications in the setting of decompensated cirrhosis in the resource constrained environment of Pakistan

“…To prevent PPCD, 8g of 20% human albumin is transfused for each liter of ascitic fluid removed when a LVP is performed. 34 , 35 Half dose albumin, 36 polygeline, 37 dextran-70 38 and normal saline 39 have been used as alternatives to albumin but without convincing results to show that they hold the same efficacy as albumin (8 gm/L of fluid removed) and are thus not recommended. If less than 5L of ascitic fluid is planned to be removed, albumin infusion can be foregone.…”

“…It improves respiratory function in such patients including those who are mechanically ventilated with minimal circulatory compromise. 35 , 40 Large volume paracentesis is better avoided in patients with spontaneous bacterial peritonitis. Some portion of fluid may be removed to bring about relief in symptoms of discomfort or respiratory distress.…”

“…Paracentesis can be performed in such cases with albumin infusion and results in improvement in renal function. 35 The standard LVP technique consists of placing an 16 G catheter over needle (Intravenous branula) into the peritoneal cavity under aseptic measures, under local anesthesia and draining the fluid into either bags or vacuum containers. The other option is an indwelling peritoneal catheter which can be used to perform paracentesis over several days, as demonstrated in certain trials.…”

“…For prevention of HRS-AKI and HRS-CKD, albumin should be administered at a dose of 8g for every litre removed when large volume paracentesis (>5L) is carried out. 35 , 45 , 117 …”

Clinical Pharmacist–Led Impact on Inappropriate Albumin Utilization and Associated Costs in General Ward Patients

“…[16][17][18] Albumin order forms have also been described as an alternative approach to improve appropriate albumin institutional use; however, sustained success may be limited from a lack of adherence to the intended use of the ordering form as a result of potential workarounds. 19,20 Strategies aimed to change health care provider prescribing patterns for albumin may require a multifaceted framework.…”