Introduction Ascites is a major complication of cirrhosis occurring in more than 50% of patients within 10 years. Tense ascites is treated with large volume paracentesis (LVP) with human albumin solution (HAS) as a plasma expander. National and International guidelines recommend that cirrhotic patients undergoing LVP (>5 l) should have 8 g of HAS per litre of ascites drained. This equates to 1 unit of 20% HAS per 2.5 l of ascites drained. HAS is not recommended for non-cirrhotic ascites or small volume paracentesis (SVP), where <5 l of ascites is drained. Our aim was to see if local practice followed guidelines.
Methods We conducted an audit of all paracenteses occurring in a London district general hospital between January 2012 and October 2013. We included day unit patients and inpatients undergoing paracentesis. We reviewed medical notes, prescription charts and nursing records, including cases with suitable documentation.
Results Sixteen patients had a total of 48 drainage episodes between them, of which 9 were male and median age was 71 years (range 45–93 years). Eleven patients had cirrhosis and 5 had non-hepatic malignancy. Table 1 demonstrates that there were 36 paracentesis episodes in cirrhotic patients where LVP was carried out with a median of 4 units of HAS given per drainage. On the other 12 occasions HAS did not need to be given. In 20/36 cases at least 2.5 l of ascites was drained for each unit of HAS given. In the 16 other cases of LVP in the cirrhotic patients, HAS was overprescribed with a total of 19 units being given unnecessarily in this group.
In total 25 units of HAS were given to patients undergoing small-volume paracentesis and those with malignant ascites. The cost per unit of HAS is £29, thus potentially £1276 could have been saved if guidelines had been followed. There were no complications associated with drain insertion nor was there any hypotension, acute kidney injury, or electrolyte disturbance related to HAS infusion.
Conclusion Albumin is often inappropriately prescribed to patients with malignant ascites and those undergoing small volume paracentesis. Of the paraceteses where HAS was indicated, 16/36 (44%) were overprescribed albumin. This has unnecessary cost implications as well as potential health risks due to the hyperoncotic properties of HAS. We conclude that reducing HAS usage by following guidelines during LVP would reduce costs without compromising patient safety.
Reference Runyon B Management of Adult Patients with Ascites due to Cirrhosis: An Update. AASLD Practice Guidelines, 2012.
Disclosure of Interest None Declared.
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