Category: Critical Care Nursing In patients with abdominal pain, cirrhosis and any degree of ascites, spontaneous bacterial peritonitis must be considered and treated appropriately. A diagnostic paracentesis may aid in directing antimicrobial therapy.
Category: Critical Care Nursing Consideration of transjugular intrahepatic portosystemic shunt (TIPS) occurs once patients require more than two paracenteses in a month. Complications include stent occlusion, liver, renal and heart failure and hepatic encephalopathy.
Category: Critical Care Nursing Transjugular intrahepatic portosystemic shunt (TIPS) involves placement of an expanding metal stent within an artificially created channel that diverts portal blood flow into the hepatic veins, thus decreasing portal hypertension and ascites.
Category: Critical Care Nursing Refractory ascites carries a mortality of 21% at 6 months and 70% at 2 years. Treatment consists of serial therapeutic paracentesis, transjugular intrahepatic portosystemic shunt (TIPS) or liver transplantation.
Category: Critical Care Nursing Refractory ascites is diagnosed when maximal medical management for at least 1 week or repeated large-volume paracenteses within 4 weeks are insufficient to remove ascites. Diuretic failure can often be a cause.
Category: Critical Care Nursing Patients with a low ascitic protein content are particularly at risk of developing spontaneous bacterial peritonitis. Treatment should start as soon as infection is suspected with a third-generation cephalosporin, such as ceftriaxone or cefotaxime.
Category: Critical Care Nursing Spontaneous bacterial peritonitis arises from translocation of intestinal bacteria, predominantly Escherichia coli and Klebsiella. Common symptoms include fever, abdominal pain, nausea and vomiting, encephalopathy and renal dysfunction.
Category: Critical Care Nursing Spontaneous bacterial peritonitis occurs in 30% of patients with ascites and is defined by: Positive bacterial culture, ascitic fluid polymorphonuclear cell count ≥250/mm3 and absence of surgically treatable source of infection.
Category: Critical Care Nursing Ascites signifies progression from compensated to decompensated liver failure and carries a 20% 1-year mortality. Within the first decade of diagnosis, 50% of patients with cirrhosis will develop ascites.
Category: Critical Care Nursing After removal of a large volume during a paracentesis, paracentesis-induced circulatory dysfunction can result from effective hypovolemia with activation of the renin-angiotensin system, resulting in hyponatremia and renal impairment.
Category: Critical Care Nursing Diuretics are started for initial control, but therapeutic paracentesis is indicated in settings of tense ascites to relieve abdominal pressure. The procedure is relatively safe when done under ultrasound guidance.
Category: Critical Care Nursing With ascites, nonsteroidal antiinflammatory drugs (NSAIDs) should be avoided, not only because of the risk of renal injury but also because they impede diuretic-mediated sodium excretion.
Category: Critical Care Nursing After addressing underlying causes of cirrhosis, including alcohol cessation or hepatitis C treatment, ascites management is focused on fluid removal. Treatment of cirrhotic ascites is salt restriction and oral diuretics to promote natriuresis.
Category: Critical Care Nursing Symptoms of ascites include weight gain, abdominal pain, fullness, early satiety and shortness of breath. Portal hypertension due to increased hepatic resistance or portal blood flow is the key pathophysiologic event in the formation of ascites.
Category: Critical Care Nursing Although computed tomography (CT) will identify ascites, ultrasound is the preferred imaging modality. It is a highly sensitive, low-cost, nonradiation-producing method that simultaneously allows evaluation of the liver and hepatic vasculature.
