Large-volume paracentesis and liver transplantation.

Abstract

To the Editor: We read with interest Kramer et al.'s article, “Large-volume paracentesis in the management of ascites in children.” The authors reviewed their experience with large-volume paracentesis (LVP) in a pediatric population and concluded that the procedure is safe and effective for managing tense abdominal ascites in children. We would like to contribute to Kramer et al.'s work with our experience in pediatric liver transplant recipients with tense abdominal ascites. Between January 1998 and September 2002, we evaluated 13 children with medically unresponsive tense ascites who underwent large-volume paracentesis before and/or after orthotopic liver transplantation (median age, 6.8 years; range, 0.6–16 years). LVP is defined as removal of 50 mL or more of ascitic fluid per kilogram of dry body weight. Forty-one LVP sessions were performed in 13 children. All of the patients had tense ascites with abdominal discomfort accompanied either by poor appetite or respiratory compromise. All patients were treated with 1 to 3 mg/kg per day of furosemide and 0.2 to 2 mg/kg per day of spironolactone. The LVP procedure was performed with the patient in the supine position. Blood products were administered if the prothrombin time was prolonged more than 3 seconds above the normal and if the platelet count was less than 30,000/mm3. We used either a 16- or 18-gauge radiopaque catheter (Abbocath™-T, Abbott Ireland, Sligo, Republic of Ireland) inserted by the Z technique. The physician or assistant observed the patient during drainage. We did not use albumin infusion during drainage because our patients were routinely receiving albumin 1 g/kg per day. The mean volume removed was 1,387 ± 820 mL. In eight sessions, the neutrophil count of the ascitic fluid was greater than 250/mm3, which was considered diagnostic for bacterial peritonitis. However, bacterial cultures in these cases were negative. Ascitic albumin concentration and LDH levels ranged from 1.2 to 2.8 g/dL (mean, SDS 1.8 ± 0.8) and 106 to 298 (mean, SDS 134.6 ± 73.8), respectively, whereas ascitic sodium concentration ranged from 98 to 132 mEq/L (mean and SDS, 17.8 ± 12.5 mEq/L). Duration of drainage ranged from 0.8 to 1 hour. All procedures were well tolerated. During drainage we did not encounter any signs of respiratory or hemodynamic instability such as hypotension, tachypnea, or decreased urine output. No significant changes in serum electrolytes, liver and renal function, or coagulation profiles were observed after LVP. Neither bacteremia nor sepsis developed as a complication of the procedure. In one patient, intraperitoneal bleeding occurred, possibly from the abdominal wall. The patient received a blood transfusion and was monitored in the intensive care unit. We did not encounter any evidence of leakage complicating any of the procedures. After LPV, improved appetite and oral intake was observed, with improved quality of life and social activity. Moreover the anxiety of parents diminished as the distension of the abdomen decreased. The role of LVP in the pediatric patient with ascites is still not clear. Although LVP is frequently used in adults for the management of tense ascites, there has been only one report of this technique in pediatric patients (1). Our experience also indicated that LVP was safe and effective in pediatric patients. After LVP, there appeared to be an increase in appetite and activity among our patients. Bhatia et al. studied esophageal body motility and LES pressures in 13 patients with cirrhosis with tense ascites in the basal state and after paracentesis (2). They demonstrated that the duration of esophageal contractions was increased in the presence of ascites and decreased after control of ascites. We speculate that improved esophageal motility could be one factor in the improved appetites of our treated patients. Although we did not assess pulmonary function in all patients, the respiratory rate of all decreased after LVP. In a recent adult study, it was suggested that LVP resulted in improved pulmonary function (3). Ascitic fluid can be removed effectively with minimal complication (1,4,5). Intraperitoneal hemorrhage is a well-known and potentially hazardous complication of paracentesis, which occurred in one patient in our series (5). The mortality of intraperitoneal hemorrhage is reported to be as high as 70% in adults, and recent studies show that severity of thrombocytopenia or coagulopathy did not increase the risk of hemorrhage in LVP (6,7). In children it is uncertain whether correction of coagulopathy would decrease the risk of hemorrhage. Kramer et al. speculate that correction of coagulopathy in children undergoing LVP may not be required (1). This issue clearly requires further study in the pediatric population. Çiğdem Arikan Funda Özgenç Sezin Aşik Akman Raşit Vural Yağci Yaman Tokat Sema Aydoğdu