Are Patients Hospitalized With Cirrhosis and Ascites Receiving Appropriate Diagnostic Paracentesis?

Abstract

Introduction: Ascites is the most common complication of cirrhosis, and is associated with increased mortality. Diagnostic paracentesis is recommended for patients who are admitted to the hospital with ascites. However, it is unknown if diagnostic paracentesis in Canadian teaching hospitals are done according to recommended guidelines. We analyzed the rate of paracentesis, determined barriers for not performing paracentesis, and the association of not performing diagnostic paracentesis with mortality. Methods: We conducted a retrospective chart review of inpatient records from January 2012 to May 2014 at 2 sites of Hamilton Health Sciences. We used electronic medical records to identify patients with cirrhosis and ascites who were admitted with a primary or secondary diagnosis of ascites, spontaneous bacterial peritonitis, or hepatic encephalopathy. All patients have to have a secondary diagnosis of cirrhosis. Primary point of interest was the performance of diagnostic paracentesis. We determined barriers for not performing and delaying paracentesis >1 day after admission. We used multiple logistic regression to study the association between age, sex, Charlson score (comorbidity score), model of endstage liver disease (MELD) score, and weekend admission for patients who received and did not receive paracentesis. Mortality and hospital stay (outcomes) were compared for those who received and did not receive paracentesis. Results: Of 162 eligible admissions, 82 (50.6%; 95% CI 42.7- 58.6%) received paracentesis. Seventyseven percent (63) of paracenteses occurred early (<1 day after admission). After adjusting for covariates, MELD was the only predictor that was significantly associated with performance of paracentesis (p=0.022). In patients who did not receive paracentesis, 46/80 (57.5%) had no documented reason for not receiving paracentesis. In patients who received delayed paracentesis, 42.1% (8) was related to seeking ultrasound (US) guidance. The mean hospital stay was longer with patients who received paracentesis (8.2) compared to those who did not receive paracentesis (7.1). In-hospital mortality was slightly higher with patients underwent paracentesis 9/82 (11%) compared to those who did not undergo paracentesis 6/80 (7.5%). Neither met statistical significance. Conclusion: In these 2 Canadian teaching centers, paracentesis was underused for patients admitted with ascites and cirrhosis. There was no clear documented reason for not receiving paracentesis in many patients. We found an increased reliance on US guidance resulted in delayed paracentesis. MELD score is the only predictor identified for receiving paracentesis. Larger studies needed to determine the effect of not performing paracentesis on mortality.