Chapter 11: Symptom control and care towards the end of life
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Source: Adapted from Marieb and Hoehn ([87]), Thibodeau and Patton ([150]).
Ascites
Definition
Ascites is an accumulation of fluid (above 25 mL) in the peritoneal cavity (Pedersen et al. [116]). Abdominal paracentesis is a simple bedside or clinic procedure in which a needle is inserted into the peritoneal cavity and ascitic fluid is removed. Diagnostic paracentesis refers to the removal of a small quantity of fluid for testing. Therapeutic paracentesis refers to the removal of 5 L or more of fluid to reduce intra‐abdominal pressure and relieve the associated dyspnoea, abdominal pain and early satiety (Runyon [129]).
Anatomy and physiology
The peritoneum is a semi‐permeable serous membrane consisting of two separate layers: the parietal layer and the visceral layer. The parietal layer covers the abdominal and pelvic walls and the undersurface of the diaphragm. The visceral layer lines and supports the abdominal organs and the parietal peritoneum (Figure 11.9). The space between the parietal and visceral layers is known as the peritoneal cavity (Marieb and Hoehn [88]). The normal peritoneal cavity has a small amount of free fluid of approximately 50 mL (Zhou et al. [168]).
Figure 11.9 Peritoneum of female in lateral view.
In a healthy individual, fluid is produced from the capillaries lining the peritoneal cavity and is drained by lymphatic vessels under the diaphragm. The fluid is collected by the right lymphatic duct, which drains into the vena cava. The peritoneum forms the largest serous membrane in the body (Tortora and Derrickson [151]) (Box 11.6). However, in patients with malignant ascites, this balance of production and drainage is disrupted and ascitic fluid collects in the peritoneal cavity.
Box 11.6
Functions of the peritoneum
- The peritoneum is a serous membrane that enables the abdominal contents to glide over each other without friction.
- It forms a partial or complete cover for the abdominal organs.
- It forms ligaments and mesenteries, which help to keep the organs in position.
- The mesenteries contain fat and act as a store for the body.
- The mesenteries can move to engulf areas of inflammation and this prevents the spread of infection.
- The peritoneum has the power to absorb fluids and exchange electrolytes.
Related theory
Ascites can be caused by non‐malignant conditions such as cirrhosis of the liver, advanced congestive heart failure, chronic pericarditis and nephrotic syndrome. Cirrhosis of the liver is the most common cause of ascites in the Western world and in this clinical condition the development of ascites indicates a poor prognosis (Tasneem et al. [147]).
Malignant conditions such as metastatic cancer of the ovary, stomach, colon or breast can also cause ascites. If a definitive diagnosis is needed to establish cause, to aid staging and possible surgical intervention, then a peritoneal tap and analysis of fluid will be useful (Runyon [130]). It is not possible to distinguish between malignant and benign ascites by physical examination or radiographic techniques so invasive testing is necessary to differentiate the two types (Sangisetty and Miner [133]).
The pathogenesis of ascites differs depending on its primary related factors:
- Cirrhotic ascites is believed to be directly related to portal hypertension (Pedersen et al. [116]).
- The increased pressure caused by fibrosis and lesions of the liver from chronic liver disease causes obstruction to venous flow.
- Heart failure and constrictive pericarditis can cause an increase in pressure on the portal venous system, leading to portal hypertension and ascites (Tasneem et al. [147]).
The pathogenesis of malignant ascites is more complex than that of non‐cancer‐related ascites. Cytokines, mechanical obstruction and hormonal influence are thought to be related. Cytokines, such as vascular endothelial growth factor (VEGF) and vascular permeability factor (VPF), regulate vascular permeability. The obstruction of lymphatic drainage by the disseminating malignant cells in the peritoneal cavity reduces absorption of peritoneal exudates (Chopra et al. [27]). This reduction activates the renin–angiotensin–aldosterone system and leads to sodium retention, which then further exacerbates the ascites.
Ascites is often accompanied by debilitating symptoms as large amounts of fluid collect in the peritoneal cavity, causing an increase in intra‐abdominal pressure and resulting in pressure on internal structures (Kipps et al. [75]). The fluid accumulation may occur over several weeks or rapidly over a few days (Lee and Grap [83]). Symptoms initially include vague abdominal discomfort, which can go on to affect the respiratory and gastrointestinal systems, depending on the amount of fluid present. Pressure on the diaphragm decreases the intrathoracic space and causes shortness of breath. Gastric pressure may cause anorexia, indigestion or hiatus hernia. Intestinal pressure may result in constipation, bowel obstruction or decreased bladder capacity. Patients also become increasingly fatigued, finding simple daily tasks difficult (Slusser [140]). Additionally, body image can be affected even when minimal distension is present.
Cytological confirmation of malignant cells is the gold standard although its sensitivity is only around 60% (Jung et al. [71]).
Evidence‐based approaches
Rationale
There is much debate about whether it is safe to drain large volumes of fluid rapidly from the abdomen. One concern is that profound hypotension may follow because of the sudden release of intra‐abdominal pressure and consequent possible vasodilation (Lindsay et al. [84]). However, some studies suggest that total paracentesis – that is, removal of all ascites (even more than 20 L) – can usually be performed safely (Pericleous et al. [117]). In cases of cirrhosis, however, Moore ([98]) suggests that when a large‐volume paracentesis is performed, it should be completed as rapidly as possible once started but at least within 6 hours, with the use of albumin to prevent hemodynamic consequences.
Martin et al. ([90]) have shown that continuous paracentesis with an indwelling peritoneal catheter can be a safe and effective means to manage patients in the hospital with large‐volume, tense ascites. This can be used for up to 72 hours and it is suggested that an intravenous albumin infusion is used to maintain optimal perfusion and renal function.
To avoid exposing patients to blood products, the use of terlipressin rather than albumin has been proposed for the prevention of paracentesis‐induced circulatory dysfunction (PICD) after large‐volume paracentesis (Annamalai et al. [4]). Initial studies suggest that terlipressin is as effective as albumin for this purpose (Shah [136]).
The literature suggests the use of ultrasound‐guided paracentesis to confirm the presence of ascites and to identify the best site to perform the procedure, particularly when a small amount of fluid is present (Montgomery and Leitman [97]).
Indications
Paracentesis may be performed:
- to obtain a specimen of fluid for analysis for diagnostic purposes (diagnostic paracentesis)
- to relieve the symptoms associated with ascites, both physical and psychological (therapeutic paracentesis)
- to administer substances such as cytotoxic drugs (e.g. bleomycin, cisplatin) or other agents into the peritoneal cavity, to achieve regression of malignant deposits (Chmielowski [26]).
Contraindications
There are a number of relative contraindications for paracentesis (Runyon [129]):
- clinically apparent disseminated intravascular coagulation
- primary fibrinolysis
- massive ileus with bowel distension
- surgical scars at the proposed paracentesis site
- symptomatic disseminated intravascular coagulation
- symptomatic hyperfibrinolysis.
An elevated international normalized ratio (INR) or thrombocytopenia is not a contraindication to paracentesis, and there is no research data supporting blood product administration prior to the procedure (Runyon [129]).
Preparatory investigations
The patient's clinical condition and the purpose of the procedure must be taken into account when deciding which investigations are necessary, but most pre‐procedural investigations include a blood screen (full blood count, coagulation screen, urea and electrolytes, liver function tests and plasma proteins) and an ultrasound examination (Runyon [128]). To keep intrusion to a minimum for palliative patients, fewer investigations may be performed. In the case of a diagnostic paracentesis or a large‐volume therapeutic paracentesis (>5 L), the ascitic fluid should be analysed for cell count, bacterial culture, total protein and albumin (Pedersen et al. [116]).
Methods of managing ascites
The development of ascites is secondary to many different conditions, and the prognosis and outlook for patients will depend on the underlying cause. Ascites can be managed, but sometimes the underlying problem cannot be resolved. For patients and families, ascites is associated with poorer quality of life and increased risk of infection (Mortimore [99]). Treatment for ascites may include use of diuretics, paracentesis, diet low in sodium, instillation of peritoneal agents or the insertion of long‐term catheters. However, the literature available is mostly generated from studies with patients suffering from acute or chronic liver failure; this should be taken into account when managing patients with non‐malignant ascites.
Paracentesis
Paracentesis is the most common way of managing ascites in a fast and effective way, as long as the loss of ascitic fluid is compensated with a low‐sodium diet, diuretic therapy and/or plasma expanders (Annamalai et al. [4]).
Sodium‐restricted diet
The amount of fluid retained in the body depends on the balance between sodium ingested in the diet and sodium excreted in the urine. The ideal sodium restriction is between 20 and 30 mEq per day or 460 and 690 mg of sodium per day (Shah [136]
), or between 1.2 and 1.7 grams per day of common salt or sodium chloride.
Diuretics
Diuretics are useful mainly in cirrhotic‐type ascites. These may be used for malignant ascites together with a restriction of salt and fluid intake, and have been found to be effective in about 43% of patients (Sangisetty and Miner [133]). Additionally, they appear to be more effective for management of patients with small‐volume ascites (only diagnosed by ultrasound). Spironolactone is the diuretic of choice (Pedersen et al. [116]). The most effective way of monitoring the fluid loss is by weighing the patient daily (Evans and Best [47]).
Chemotherapy
Instillation of heated intraperitoneal chemotherapy has successfully been used in reducing and eventually eliminating malignant ascites (Sangisetty and Miner [133]).
Long‐term catheters
There are three types of catheter that can be used for long‐term management of ascites:
- Peritoneovenous shunt: these are generally used in patients with a long‐term prognosis. These shunts drain ascitic fluid into the superior vena cava and require general anaesthesia for insertion (Christensen et al. [28]).
- PleurX drain: this is a tunnelled catheter placed under ultrasound and fluoroscopic guidance. This device is associated with low rates of serious adverse clinical events, catheter failure, discomfort and electrolyte imbalance (Narayanan et al. [100]). Additionally, it may allow patients to avoid spending added time in hospital for repeated paracentesis.
- Peritoneal port‐catheter: this is similar to but larger than a central venous catheter. It allows long‐term drainage with reduced infection risk (Ghaffar et al. [53]). A limited number of studies support its use.
Clinical governance
Competencies
The procedure is performed by a doctor or a practitioner trained in paracentesis, assisted by a nurse throughout. There is no accredited pathway or course for learning this clinical skill and specific training has to be negotiated and developed locally (Vaughan [158]).
Pre‐procedural considerations
Equipment
The equipment should be prepared by the health professional performing the paracentesis or by a colleague familiar with the technique. Nurses should describe the equipment to be used during paracentesis to the patient. This may be more relevant when looking after a patient undergoing the procedure for the first time, to whom the size of the catheter used may be concerning.
Assessment and recording tools
A detailed nursing assessment is important when caring for patients requiring paracentesis. Nurses should pay particular attention to the cause of the ascites and the frequency with which the procedure is occurring. The involvement of the palliative care team can at this stage be indicated. As well as assessing the patient's psychological wellbeing, nurses must pay attention to the skin condition and pain levels.
In preparation for the paracentesis, nurses should measure the patient's girth around the umbilicus and check the patient's weight before the procedure. The same chart should be used to record all subsequent measurements so a comparison can be made.
Pharmacological support
The health professional performing the paracentesis must use a local anaesthetic, and lidocaine at the concentration of 1% is often the drug of choice. The lidocaine is injected subcutaneously initially with a 25 G needle and subsequently with a 23 G needle until optimal pain control is achieved, not to exceed the maximum dose of 4.5 mg/kg (or 200 mg). Optimal pain control can take between 2 and 5 minutes after the drug is injected and it is important for the practitioner to assess the effectiveness of the local anaesthetic before starting the procedure. Lorazepam at a dose of 1 mg can be of benefit prior to the procedure for patients who are anxious, due to its muscle relaxant and anxiolytic effects.
Non‐pharmacological support
Nurses should enquire about the patient's fears and concerns regarding paracentesis. For some patients, music, relaxation and visualization techniques are of great benefit so the use of these approaches should be considered, if available.
Specific patient preparation
Education
Nursing interventions for patients undergoing abdominal paracentesis include education about the nature of the procedure, what results can realistically be expected, and the risks and benefits. Information should also be given about post‐procedure care of the puncture site and about the importance of diet and fluid intake to replace proteins and fluid lost in the ascitic fluid. It is essential that the patient, their family and their carers are involved in the discussion so that an informed and joint decision may be made in order to achieve the best possible outcome.
Procedure guideline 11.3
Abdominal paracentesis
Table 11.6 Prevention and resolution (Procedure guideline 11.3)
| Problem | Cause | Prevention | Suggested action |
|---|---|---|---|
| Patient exhibits shock | Major circulatory shift of fluid or sudden release of intra‐abdominal pressure, vasodilation and subsequent lowering of blood pressure | Monitor blood pressure and consider administration of intravenous fluid if volumes larger than 5 L are expected to drain. | Clamp the drainage tube with a gate clamp to prevent further fluid loss. Record the patient's vital signs. Refer to the medical staff for immediate intervention. |
| Cessation of drainage of ascitic fluid | Abdomen is empty of ascitic fluid | Check the total output of ascitic fluid given on the patient's fluid balance chart. Measure the patient's girth; compare this measurement with the pre‐abdominal paracentesis measurement. Suggest to the medical staff that the cannula should be removed. Discontinue the drainage system. | |
| Patient's position is inhibiting drainage | Teach the patient to avoid exerting pressure on the drainage tubing. | Assist the patient to change position – ideally to sit upright or to lie on their side to encourage flow by gravity. Encourage the patient to mobilize. | |
| The ascitic fluid has clotted in the drainage system | Keep the drainage bag on a stand and lower than the puncture site to facilitate drainage by gravity. | ‘Milk’ the tubing. If this is unsuccessful, change the drainage system aseptically. Refer to the medical staff. | |
| Cannula becomes dislodged | Ineffective sutures or trauma at the puncture site | Collaborate with medical staff when applying the suture or alternatively apply a secure dressing. The tube can be taped to the skin further down to prevent pulling with movement at the puncture site. | Apply a secure, dry dressing. Reassure the patient. Inform the medical staff. |
| Pain | Pressure of ascites or position of drain | Offer analgesia 30 minutes prior to the procedure. Apply the dressing in such a way as to allow enough padding around the puncture site but avoid drain movement within the abdomen. | Identify the cause. Anchor the drain securely to avoid pulling at the insertion site or movement within the abdomen. Assist the patient with repositioning. Administer an appropriate prescribed analgesic; monitor the patient's response and inform medical staff. |
Post‐procedural considerations
Immediate care
Observations must be carried out every 30 minutes for 2 hours and hourly for 4 hours to detect early signs of shock, cardiovascular compromise and infection so that medical staff can be informed and action can be taken promptly. Drainage of the fluid must be monitored regularly, volumes recorded on a fluid balance chart and blockages detected and managed. Patients may require assistance to move and position themselves, and they may experience pain, requiring careful repositioning or appropriate analgesia.
All paracentesis should be completed as rapidly as possible and all ascetic drains should be removed within 4 to 6 hours of commencing the paracentesis to prevent infection (Moore [98]). The patient's renal function should be checked following this procedure to ensure that any signs of dehydration or pre‐renal failure are treated as early as possible.
Patients should be informed that leakage following removal of the drain may happen and should be reported promptly.
Complications
Bleeding
Haemorrhagic complications of paracentesis are generally divided into three groups: abdominal wall hematoma, pseudoaneurysm and haemoperitoneum. The likelihood of requiring a transfusion following paracentesis is about 0.3% (Sharzehi et al. [137]).
Abdominal wall hematoma is the most frequently occurring haemorrhagic complication. Pseudoaneurysms of the inferior epigastric artery represent two‐thirds of all of these haemorrhagic complications. Haemoperitoneum, which is usually the result of injury to a mesenteric varix, is responsible for close to one‐third of these complications (Sharzehi et al. [137]).
Paracentesis‐induced circulatory dysfunction
The removal of large fluid volumes may result in impaired circulatory function for up to 6 days after paracentesis. Paracentesis‐induced circulatory dysfunction (PICD) is clinically silent and not spontaneously reversible. The occurrence of PICD is associated with rapid recurrence of ascites, renal failure and a significant decrease in the probability of survival (Annamalai et al. [4]).
Local infection or peritonitis
There is the risk of introducing infection into the ascitic fluid, which can be minimized by the use of sterile technique. A swab from the site of the cannula should be obtained for culture review and a dry dressing applied.
Bowel or bladder perforation
This risk is decreased by ensuring the patient has an empty bladder and avoiding sites of scarring on the abdomen when inserting the cannula, as these may indicate internal adhesions between the bowel and peritoneum.
