Management of refractory ascites. Am J Ther. 2012;19:121-132. [PMID: 21192246 DOI: 10.1097/mjt.0b013e3181ff7a8b]

In Patients Undergoing CRS/HIPEC for Colorectal Adenocarcinoma with Peritoneal Metastases, Presence of Ascites on Computed Tomography Imaging is not a Prognostic Marker for Survival

Background

Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is a potentially curative treatment for patients with colorectal peritoneal metastases (CRPM). Patient selection is key to optimizing outcomes after CRS/HIPEC. The aim of this study was to determine the prognostic value of ascites diagnosed on preoperative imaging.

Methods

A prospective database of patients eligible for CRS/HIPEC between 2010 and 2020 was retrospectively analyzed. The presence of ascites, postoperative complications, overall survival (OS), disease-free survival (DFS), and completeness of cytoreduction were assessed. Univariable and multivariable logistic regression was performed to identify independent predictors for outcome.

Results

Of the 235 included patients, 177 (75%) underwent CRS/HIPEC while 58 (25%) were not eligible for CRS/HIPEC. In 42 of the 177 patients (24%) who underwent CRS/HIPEC, ascites was present on preoperative computed tomography (CT) imaging. Peritoneal Cancer Index (PCI) score was significantly higher in patients with preoperative ascites compared with patients without (11 [range 2–30] vs. 9 [range 0–28], respectively; p = 0.011) and complete cytoreduction was more often achieved in patients without ascites (96.3% vs. 85.7%; p = 0.007). There was no significant difference in median DFS and OS after CRS/HIPEC between patients with and without ascites {10 months (95% confidence interval [CI] 7.1–12.9) vs. 9 months (95% CI 7.2–10.8), and 25 months (95% 9.4–40.6) vs. 27 months (95% CI 22.4–31.6), respectively}.

Conclusions

Ascites on preoperative imaging was not associated with worse survival in CRS/HIPEC patients with CRPM. Therefore, excluding patients from CRS/HIPEC based merely on the presence of ascites is not advisable.

Is the Sympathetic System Detrimental in the Setting of Septic Shock, with Antihypertensive Agents as a Counterintuitive Approach? A Clinical Proposition

Mortality in the setting of septic shock varies between 20% and 100%. Refractory septic shock leads to early circulatory failure and carries the worst prognosis. The pathophysiology is poorly understood despite studies of the microcirculatory defects and the immuno-paralysis. The acute circulatory distress is treated with volume expansion, administration of vasopressors (usually noradrenaline: NA), and inotropes. Ventilation and anti-infectious strategy shall not be discussed here. When circulation is considered, the literature is segregated between interventions directed to the systemic circulation vs. interventions directed to the micro-circulation. Our thesis is that, after stabilization of the acute cardioventilatory distress, the prolonged sympathetic hyperactivity is detrimental in the setting of septic shock. Our hypothesis is that the sympathetic hyperactivity observed in septic shock being normalized towards baseline activity will improve the microcirculation by recoupling the capillaries and the systemic circulation. Therefore, counterintuitively, antihypertensive agents such as beta-blockers or alpha-2 adrenergic agonists (clonidine, dexmedetomidine) are useful. They would reduce the noradrenaline requirements. Adjuncts (vitamins, steroids, NO donors/inhibitors, etc.) proposed to normalize the sepsis-evoked vasodilation are not reviewed. This itemized approach (systemic vs. microcirculation) requires physiological and epidemiological studies to look for reduced mortality.

Radiologically Placed Peritoneovenous Shunt is an Acceptable Treatment Alternative for Refractory Ascites Due to End-Stage Liver Disease

PURPOSE

To compare patients treated with large-volume paracentesis (LVP), transjugular intrahepatic portosystemic shunt (TIPS), and peritoneovenous shunt (PVS) for ascites.

MATERIALS AND METHODS

A retrospective study of 192 patients treated with LVP (94), TIPS (75), or PVS (23) was performed. Records were reviewed for patient characteristics and outcomes. The patients' age differed (LVP, 59.5 years; TIPS, 58.8 years; and PVS, 65.6 years; P = .003). Nonalcoholic steatohepatitis was the most common etiology in the PVS cohort (11/23, 47%), and hepatitis C in the TIPS (27/75, 36%), and LVP cohorts (43/94, 46%) (P = .032). The model for end-stage liver disease score was significantly different (LVP, 14; TIPS, 13; and PVS, 8; P = .035). Hepatocellular carcinoma was higher in the PVS cohort (6/23 patients, 25%) than in the TIPS (4/75, 5%), and LVP (12/94, 12%) cohorts (P = .03).

RESULTS

Emergency department visits and hospital readmissions were the highest in the LVP cohort (40%, ≥2 readmissions, P < .001). Patients required fewer LVPs after TIPS (1.5 to 0.14, P < .001) or PVS (2.1 to 0.5, P = .019). In an unadjusted Cox model, patients in the TIPS cohort were found to have a 58% reduction in the risk of death compared with patients in the LVP cohort (P = .003). Transplant-free survival (PVS, 44 days; TIPS, 155 days; and LVP, 213 days) differed (log rank = 0.001).

CONCLUSIONS

The survival in the PVS and TIPS cohorts was similar, with less healthcare utilization than the LVP cohort. PVS is a satisfactory alternative to LVP.

Clinical Practice: Should we Radically Alter our Sedation of Critical Care Patients, Especially Given the COVID-19 Pandemics?

The high number of patients infected with the SARS-CoV-2 virus requiring care for ARDS puts sedation in the critical care unit (CCU) to the edge. Depth of sedation has evolved over the last 40 years (no-sedation, deep sedation, daily emergence, minimal sedation, etc.). Most guidelines now recommend determining the depth of sedation and minimizing the use of benzodiazepines and opioids. The broader use of alpha-2 adrenergic agonists ('alpha-2 agonists') led to sedation regimens beginning at admission to the CCU that contrast with hypnotics+opioids ("conventional" sedation), with major consequences for cognition, ventilation and circulatory performance. The same doses of alpha-2 agonists used for 'cooperative' sedation (ataraxia, analgognosia) elicit no respiratory depression but modify the autonomic nervous system (cardiac parasympathetic activation, attenuation of excessive cardiac and vasomotor sympathetic activity). Alpha-2 agonists should be selected only in patients who benefit from their effects ('personalized' indications, as opposed to a 'one size fits all' approach). Then, titration to effect is required, especially in the setting of systemic hypotension and/or hypovolemia. Since no general guidelines exist for the use of alpha-2 agonists for CCU sedation, our clinical experience is summarized for the benefit of physicians in clinical situations in which a recommendation might never exist (refractory delirium tremens; unstable, hypovolemic, hypotensive patients, etc.). Because the physiology of alpha-2 receptors and the pharmacology of alpha-2 agonists lead to personalized indications, some details are offered. Since interactions between conventional sedatives and alpha-2 agonists have received little attention, these interactions are addressed. Within the existing guidelines for CCU sedation, this article could facilitate the use of alpha-2 agonists as effective and safe sedation while awaiting large, multicentre trials and more evidence-based medicine.

Exploring a New Management Option for Patients With Refractory Ascites: The PeriLeve Device

Cirrhosis of the liver is often accompanied by refractory ascites, a condition characterized by fluid buildup in the peritoneal cavity that does not respond to diuretics or recurs shortly after therapeutic paracentesis. There are several management strategies in practice including large-volume paracentesis, transjugular intrahepatic portosystemic shunts, peritoneovenous shunting, and liver transplant. However, each of these options come with limitations such as high cost, poor efficacy, and increased risk of complications. This article explores a new management strategy with a novel biopowered shunt, the PeriLeve device, that moves fluid from the peritoneal cavity to the urinary bladder using natural changes in intra-abdominal pressure (IAP). By doing so, PeriLeve shifts the current paradigm of care from the hospital to the home which reduces costs to healthcare providers and patients while improving quality of life. The basic design of the pump consists of two check (i.e., one-way) valves on either side of a fluid filled cavity which is separated from an air cavity by an elastomeric membrane. This article presents benchtop testing results of a prototype PeriLeve pump. The performance of the pump was analyzed along six parameters: change in intra-abdominal pressure, valve opening pressure, membrane thickness, membrane stiffness, membrane surface area, and air cavity volume. Initial results indicate that, with future optimizations, the pump can ultimately move a clinically significant volume of fluid.

Paracentesis-induced circulatory dysfunction: are there albumin alternatives?

Background

Ascites is one of the main complications of advanced liver cirrhosis. It is defined as a pathological accumulation if free fluid in the peritoneal cavity.

Main body of the abstract

Ascites is a sign of decompensation in patients with liver cirrhosis and is associated with decreased survival. Ascites is associated with bad cosmetic figure and poor quality of life. Ascites is a predisposing factor for developing hydrothorax, hernias, diastolic dysfunction, spontaneous bacterial peritonitis, and renal impairment especially hepatorenal syndrome. The main treatment is salt restriction and diuretics. By the time the patient become non-responder and develop tense ascites, abdominal large volume paracentesis is the treatment of choice. Its advantages are rapid, cheap, and 1 day hospitalization. The main drawback is the development of paracentesis-induced circulatory dysfunction (PICD) if no volume expanding drugs are used. PICD is associated with dilutional hyponatremia, renal impairment, so it is considered the silent killer. Albumin infusion is the standard preventive measure but since costly to other alternatives such as colloids, vasoconstrictors or lowering the standard doses of the albumin was studied and is promising.

Conclusions

This review summarized the effectiveness of other alternative drugs.

Combined treatment of refractory ascites with an alfapump® plus hernia repair in the same surgical session: A retrospective, multicentre, European pilot study in cirrhotic patients

INTRODUCTION

The treatment of symptomatic hernia in cirrhotic patients with refractory ascites is critical but challenging. The objective of this study was to assess the feasibility and safety of the implantation of alfapump® combined with concomitant hernia repair in cirrhotic patients with refractory ascites.

METHODS

Using data from six European centres, we retrospectively compared patients treated with alfapump® system implantation and concomitant hernia repair [the combined treatment group (CT group, n=12)] or with intermittent paracentesis hernia repair [the standard treatment group (ST group, n=26)]. Some patients of the ST group had hernia repair in an elective setting (STel group) and others in emergency (STem group). The endpoints were requirement of peritoneal drainage, the rate of infectious complications, the in-hospital mortality, the length of stay, paracentesis-free survival.

RESULTS

Postoperatively, none of the patients in the CT group and 21 patients (80%) in the ST group underwent peritoneal drainage for the evacuation of ascites fluid (P<0.0001). The overall incidence of infectious complications was not different between groups but there were fewer infections in the CT group than in the STem group (33% vs. 81%; P=0.01). There was no difference for in-hospital mortality. The length of stay was shorter in the CT group (P=0.03). Paracentesis-free survival was significantly better (P=0.0003) in the CT group than in the ST group.

CONCLUSION

Implantation of alfapump combined with concomitant hernia repair seems feasible and safe in cirrhotic patients; however, larger and randomized study are required.

How to care for patients undergoing paracentesis for the drainage of ascites

RATIONALE AND KEY POINTS

Ascites is the excessive accumulation of extracellular fluid within the peritoneal cavity, which usually develops as a result of cirrhosis of the liver. Paracentesis is the procedure for removing ascitic fluid from the transabdominal peritoneal cavity via a temporary ascitic drain. This article aims to support nurses in providing safe and effective care for patients undergoing paracentesis. • Paracentesis is used to reduce intra-abdominal pressure and to relieve the symptoms of abdominal ascites, such as severe abdominal distention, pain and dyspnoea (difficulty breathing). The removal of at least 5L of ascitic fluid is considered large-volume paracentesis.• The role of the nurse is usually to monitor the patient throughout the procedure, administer treatment as directed by the medical team and, depending on local policy, remove the drain at the end of the procedure.• Knowledge of the benefits and risks of this procedure is essential to provide safe, evidence-based care for patients undergoing paracentesis. REFLECTIVE ACTIVITY: 'How to' articles can help to update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of: 1. How reading this article will change your practice in caring for patients undergoing paracentesis.2. How this article could be used to educate patients who are due to undergo paracentesis.

An update on the pathogenesis and clinical management of cirrhosis with refractory ascites

Ascites commonly complicates cirrhosis, becoming refractory to treatment with diuretics and sodium restriction in approximately 10% of patients. Pathogenesis of refractory ascites (RA) is multifactorial, the common final pathway being renal hypoperfusion and avid sodium retention. Refractory ascites has a negative prognostic implication in the natural history of cirrhosis. Management of RA include sodium restriction and regular large volume paracentesis (LVP) with albumin infusions, preventing paracentesis-induced circulatory dysfunction. In appropriate setting, transjugular intrahepatic porto-systemic shunt (TIPS) can be considered. Ascites clearance with TIPS can lead to nutritional improvement, avoiding sarcopenia. Liver transplantation (LT) remains the definitive treatment for eligible candidates. Areas covered: Our review summarizes current updates on pathogenesis and clinical management of RA including potential future therapeutic options such as the automated slow-flow ascites pump, chronic outpatient albumin infusion and cell-free and concentrated ascites reinfusion therapy. Expert commentary: Standard of care in patients with RA include LVP with albumin replacement and prompt referral for LT where indicated. Other novel therapeutic options on the horizon include automated low-flow ascites pump and cell-free, concentrated albumin reinfusion therapy.

Refractory Ascites in Liver Cirrhosis

Ascites, a common complication of liver cirrhosis, eventually becomes refractory to diuretic therapy and sodium restriction in ∼10% of patients. Multiple pathogenetic factors are involved in the development of refractory ascites, which ultimately lead to renal hypoperfusion and avid sodium retention. Therefore, renal dysfunction commonly accompanies refractory ascites. Management includes continuation of sodium restriction, which needs frequent reviews for adherence; and regular large volume paracentesis of 5 L or more with albumin infusions to prevent the development of paracentesis-induced circulatory dysfunction. In the appropriate patients with reasonable liver reserve, the insertion of a transjugular intrahepatic portosystemic stent shunt (TIPS) can be considered, especially if the patient is relatively young and has no previous hepatic encephalopathy or anatomical contraindications, and no past history of renal or cardiopulmonary disease. Response to TIPS with ascites clearance can lead to nutritional improvement. Devices such as an automated low-flow ascites pump may be available in the future for ascites treatment. Patients with refractory ascites and poor liver function and/or renal dysfunction, should be referred for liver transplant, as this will eliminate the portal hypertension and liver dysfunction. Renal dysfunction prior to liver transplant largely improves after transplant without affecting post-transplant survival.

Hypothesis: Fever control, a niche for alpha-2 agonists in the setting of septic shock and severe acute respiratory distress syndrome?

During severe septic shock and/or severe acute respiratory distress syndrome (ARDS) patients present with a limited cardio-ventilatory reserve (low cardiac output and blood pressure, low mixed venous saturation, increased lactate, low PaO2/FiO2 ratio, etc.), especially when elderly patients or co-morbidities are considered. Rescue therapies (low dose steroids, adding vasopressin to noradrenaline, proning, almitrine, NO, extracorporeal membrane oxygenation, etc.) are complex. Fever, above 38.5-39.5°C, increases both the ventilatory (high respiratory drive: large tidal volume, high respiratory rate) and the metabolic (increased O2 consumption) demands, further limiting the cardio-ventilatory reserve. Some data (case reports, uncontrolled trial, small randomized prospective trials) suggest that control of elevated body temperature ("fever control") leading to normothermia (35.5-37°C) will lower both the ventilatory and metabolic demands: fever control should simplify critical care management when limited cardio-ventilatory reserve is at stake. Usually fever control is generated by a combination of general anesthesia ("analgo-sedation", light total intravenous anesthesia), antipyretics and cooling. However general anesthesia suppresses spontaneous ventilation, making the management more complex. At variance, alpha-2 agonists (clonidine, dexmedetomidine) administered immediately following tracheal intubation and controlled mandatory ventilation, with prior optimization of volemia and atrio-ventricular conduction, will reduce metabolic demand and facilitate normothermia. Furthermore, after a rigorous control of systemic acidosis, alpha-2 agonists will allow for accelerated emergence without delirium, early spontaneous ventilation, improved cardiac output and micro-circulation, lowered vasopressor requirements and inflammation. Rigorous prospective randomized trials are needed in subsets of patients with a high fever and spiraling toward refractory septic shock and/or presenting with severe ARDS.

Risk factors for development of surgical site infections among liver transplantation recipients: An integrative literature review

BACKGROUND

Surgical site infection (SSI) is an important complication in the postoperative period of recipients of liver transplantation. The purpose of this integrative literature review is to summarize the knowledge available about the risk factors contributing to the development SSI among adults undergoing liver transplantation.

METHODS

We reviewed the Medical Literature Analysis and Retrieval System Online/PubMed, the Cumulative Index to Nursing and Allied Health Literature, the Latin American and Caribbean Health Sciences Literature, Scopus, and Web of Science databases.

RESULTS

Two hundred sixteen articles were identified and the final sample of 9 articles was analyzed in full length. The SSI rate found in the investigations ranged between 9.6% and 35.5%. Risk factors for SSI were grouped into categories related to the preoperative period, such as Model for End-Stage Renal Disease score > 35 and ventilated support on day of transplant; to the intraoperative period activity, such as transfusion of packed red blood cells, extended surgical time, hyperglycemia >200 mg/dL, use of vasopressor drugs, and ascites flow >1 L; and to the donor/recipient relationship, such as age differences >10 years, ratio of donor liver mass to recipient body mass < 0.01. Additionally, centers that annually perform <50 transplants appear to have higher rates of SSI.

CONCLUSIONS

Few studies have addressed the subject of SSI in relation to liver transplantation in the scientific literature. Risk factors for SSI in patients who underwent liver transplantation vary between institutions.

Efficacy of tolvaptan for the patients with advanced hepatocellular carcinoma

AIM

To investigate the factors influenced the efficacy of tolvaptan (TLV) in liver cirrhosis.

METHODS

We retrospectively enrolled 61 consecutive patients with refractory hepatic ascites. All of them had been treated with furosemide and spironolactone before admission, and treated with TLV for 7 d in our hospital. The effect of TLV was defined by the rate of body weight loss, and the factors that influenced TLV efficacy were analyzed using multiple regression.

RESULTS

Coexistent hepatocellular carcinoma (HCC) was the only significant predictive variable that attenuated the efficacy of TLV. In stratified analysis, high doses of furosemide decreased the efficacy of TLV in patients with HCC, and increased efficacy in those without HCC. In the latter, a high Child-Pugh-Turcotte score had a positive influence and a high concentration of lactate dehydrogenase had a negative influence on the effectiveness of TLV.

CONCLUSION

Development of ascites may differ between patients with liver failure and those with HCC progression. A sufficient preceding dose of furosemide decreases diuretic effect of TLV.

Ascites, refractory ascites and hyponatremia in cirrhosis

Ascites is the most common complication related to cirrhosis and is associated with increased morbidity and mortality. Ascites is a consequence of the loss of compensatory mechanisms to maintain the overall effective arterial blood volume due to worsening splanchnic arterial vasodilation as a result of clinically significant portal hypertension. In order to maintain effective arterial blood volume, vasoconstrictor and antinatriuretic pathways are activated, which increase overall sodium and fluid retention. As a result of progressive splanchnic arterial vasodilation, intestinal capillary pressure increases and results in the formation of protein-poor fluid within the abdominal cavity due to increased capillary permeability from the hepatic sinusoidal hypertension. In some patients, the fluid can translocate across diaphragmatic fenestrations into the pleural space, leading to hepatic hydrothorax. In addition, infectious complications such as spontaneous bacterial peritonitis can occur. Eventually, as the liver disease progresses related to higher portal pressures, loss of a compensatory cardiac output and further splanchnic vasodilation, kidney function becomes compromised from worsening renal vasoconstriction as well as the development of impaired solute-free water excretion and severe sodium retention. These mechanisms then translate into significant clinical complications, such as refractory ascites, hepatorenal syndrome and hyponatremia, and all are linked to increased short-term mortality. Currently, liver transplantation is the only curative option for this spectrum of clinical manifestations but ongoing research has led to further insight on alternative approaches. This review will further explore the current understanding on the pathophysiology and management of ascites as well as expand on two advanced clinical consequences of advanced liver disease, refractory ascites and hyponatremia.

The Palliative Management of Refractory Cirrhotic Ascites Using the PleurX (©) Catheter

Background. Treatment options are limited for patients with refractory cirrhotic ascites (RCA). As such, we assessed the safety and effectiveness of the PleurX catheter for RCA. Methods. A retrospective analysis was performed on all patients with RCA who have undergone insertion of the PleurX catheter between 2007 and 2014 at our clinic. Results. Thirty-three patients with RCA were included in the study; 4 patients were lost to follow-up. All patients were still symptomatic despite bimonthly large volume paracentesis and were not candidates for TIPS or PV shunt. Technical success was achieved in 100% of patients. The median duration the catheter remained in situ was 117.5 days, with 95% CI of 48-182 days. Drain patency was maintained in 90% of patients. Microorganisms consistent with spontaneous bacterial peritonitis (SBP) from a catheter source were isolated in 38% of patients. The median time to infection was 105 days, with 95% CI of 34-233 days. All patients were treated for SBP successfully with antibiotics. Conclusion. Use of the PleurX catheter for the management of RCA carries a high risk for infection when the catheter remains in situ for more than 3 months but has an excellent patency rate and did not result in significant renal injury.

Efficacy of octreotide for treatment of cirrhosis with refractory ascites: A meta-analysis

AIM: To evaluate the efficacy and safety of octreotide in the treatment of cirrhosis with refractory ascites.

METHODS: PubMed, EMBASE, CBM, CNKI, VIP and Wanfang Database were searched to retrieved studies evaluating the efficacy of octreotide in the treatment of cirrhosis with refractory ascites. All the related data that met our standards were extracted. The quality of the included trials was evaluated according to the Jadad score. RevMan 5.2 software was used for meta-analysis.

RESULTS: A total of 9 randomized controlled trials involving 696 patients were included. The results of meta-analysis showed that the octreotide group was superior to the control group in treatment efficiency (OR = 3.18, 95%CI: 2.03-4.97, P < 0.00001), weight reduction (MD = -8.75, 95%CI: -11.25--6.25, P < 0.00001), ascites reduction (SMD = -31.8, 95%CI: -35.23--28.37, P < 0.00001), decreased abdominal girth (SMD = -8.75, 95%CI: -11.55--5.95, P < 0.00001), increased blood urea nitrogen (BUN) (MD = -1.18, 95%CI: -2.31--0.06, P = 0.04) and 24 h urine volume (SMD = 8.18, 95%CI: 3.69-12.67, P = 0.0004), but there was no statistical difference in serum creatinine (sCr) or portal vein trunk diameter (PVD).

CONCLUSION: Current evidence suggests that octreotide could improve treatment efficiency in terms of weight reduction, ascites reduction, decreased abdominal girth, increased BUN and 24 h urine volume.

Portal hypertension: a review of portosystemic collateral pathways and endovascular interventions

The portal vein is formed at the confluence of the splenic and superior mesenteric vein behind the head of the pancreas. Normal blood pressure within the portal system varies between 5 and 10 mmHg. Portal hypertension is defined when the gradient between the portal and systemic venous blood pressure exceeds 5 mmHg. The most common cause of portal hypertension is cirrhosis. In cirrhosis, portal hypertension develops due to extensive fibrosis within the liver parenchyma causing increased vascular resistance. In addition, the inability of the liver to metabolise certain vasodilators leads to hyperdynamic splanchnic circulation resulting in increased portal blood flow. Decompression of the portal pressure is achieved by formation of portosystemic collaterals. In this review, we will discuss the pathophysiology, anatomy, and imaging findings of spontaneous portosystemic collaterals and clinical manifestations of portal hypertension with emphasis on the role of interventional radiology in the management of complications related to portal hypertension.

Clinical efficacy of tolvaptan for treatment of refractory ascites in liver cirrhosis patients

AIM

To evaluate the efficacy and safety of tolvaptan to treat refractory ascites in decompensated liver cirrhosis patients with or without further complications, such as hepatorenal syndrome and/or hepatocellular carcinoma.

METHODS

Thirty-nine patients (mean age 55 years, males: 32) with decompensated liver cirrhosis and refractory ascites were enrolled. All patients received a combination of tolvaptan (15 mg/d for 5-14 d) and diuretics (40-80 mg/d of furosemide and 80-160 mg/d of spironolactone). The etiology of cirrhosis included hepatitis B (69.2%), hepatitis C (7.7%) and alcohol-induced (23.1%). Changes in the urine excretion volume, abdominal circumference and edema were assessed. The serum sodium levels were also measured, and adverse events were recorded. A follow-up assessment was conducted 1 mo after treatment with tolvaptan.

RESULTS

Tolvaptan increased the mean urine excretion volume (1969.2 ± 355.55 mL vs 3410.3 ± 974.1 mL, P < 0.001), and 89.7% of patients showed improvements in their ascites, 46.2% of whom showed significant improvements. The overall efficacy of tolvaptan in all patients was 89.7%; the efficacies in patients with hepatocellular carcinoma and hepatorenal syndrome were 84.2% and 77.8%, respectively. The incidence of hyponatremia was 53.8%. In patients with hyponatremia, the serum sodium levels increased after tolvaptan treatment (from 128.1 ± 4.22 mEq/L vs 133.1 ± 3.8 mEq/L, P < 0.001). Only mild drug-related adverse events, including thirst and dry mouth, were observed.

CONCLUSION

Tolvaptan is a promising aquaretic for the treatment of refractory ascites in patients with decompensated liver cirrhosis.

Ascitic Fluid Analysis in the Differential Diagnosis of Ascites: Focus on Cirrhotic Ascites

Ascites is the pathologic accumulation of fluid within the peritoneal cavity. Because many diseases can cause ascites, in particular cirrhosis, samples of ascitic fluid are commonly analyzed in order to develop a differential diagnosis. The concept of transudate versus exudate, as determined by total protein measurements, is outdated and the use of serum-ascites albumin gradient as an indicator of portal hypertension is more accurate. Lactate dehydrogenase (LDH), vascular endothelial growth factor (VEGF), and other tumor markers can be helpful in distinguishing between malignant and benign conditions. Glucose and adenosine deaminase levels may support a diagnosis of tuberculous disease, and amylase level may indicate a diagnosis of pancreatitis. Given the specificity and sensitivity of laboratory results, accurate diagnosis should be based on both laboratory data and clinical judgment.

Tunneled peritoneal drainage catheter placement for refractory ascites: single-center experience in 188 patients

PURPOSE

To assess the success and safety of tunneled peritoneal drainage catheters for the management of ascites refractory to medical management.

MATERIALS AND METHODS

A total of 188 consecutive patients (83 male, 105 female; average age 59 y) with refractory ascites were treated with tunneled peritoneal drainage catheters from January 1, 2006, to August 10, 2012. A combination of fluoroscopic and ultrasound guidance was used to insert all catheters. Patient history, procedural records, and clinical follow-up documents were retrospectively reviewed. Clinical data (malignancy, renal disease, chemotherapy, neutropenia, albumin levels) were compared with respect to patency and complication rates with the use of odds ratios. Catheter survival curves were generated with the Kaplan-Meier method and life-table analysis for the cumulative and infection-free survival of primary and secondary catheters.

RESULTS

A total of 193 catheter placements or interventions were performed in 188 patients with refractory ascites: 170 catheters (93%) were placed for malignant etiologies and 13 (7%) for nonmalignant etiologies. The most common malignancies were ovarian (22%), pancreatic (12%), and breast (11%). The most common nonmalignant etiologies were end-stage liver disease (n = 7) and heart failure (n = 6). There was a 100% technical success rate for catheter insertion; no procedure-related deaths or major placement complications were identified. Catheter survival ranged from 0 to 796 days (mean, 60 d), with a total of 11,936 cumulative catheter-days. Fourteen postplacement complications were identified: five patients experienced catheter malfunction, four had leakage of ascites at the incisional site requiring suture placement, three had cellulitis of the tunnel tract, and two developed peritonitis. The annual complication event rate was 0.43 events per year (ie, 0.12 events per 100 catheter-days). Pancreatic malignancy was associated with a significantly increased rate of catheter malfunction (ie, occlusion).

CONCLUSIONS

Radiologic insertion of tunneled peritoneal drainage catheters demonstrated a 100% technical success rate for insertion and an acceptable complication rate for the management of refractory ascites.

[Dexmedetomidine and clonidine: a review of their pharmacodynamy to define their role for sedation in intensive care patients]

Alpha-2 adrenergic agonists ("alpha-2 agonists") present multiple pharmacodynamic effects: rousable sedation, decreased incidence of delirium in the setting of critical care, preservation of respiratory drive, decreased whole body oxygen consumption, decreased systemic and pulmonary arterial impedance, improved left ventricular systolic and diastolic function, preserved vascular reactivity to exogenous catecholamines, preserved vasomotor baroreflex with lowered set point, preserved kidney function, decreased protein catabolism. These pharmacodynamic effects explain the interest for these drugs in the critical care setting. However, their exact role for sedation in critically ill-patients remains open for further studies. Given the few double-blind randomized multicentric trials available, the present non exhaustive analysis of the literature aims at presenting the utilization of alpha-2 agonists as potential first-line sedative agents, in the critical care setting. Suggestions regarding the use of alpha-2 agonists as sedatives are detailed.