Background

Ascites is the most common complication of liver cirrhosis, and infection of that abdominal fluid, spontaneous bacterial perotinitis (SBP) is both common (reported in 10-30% of hospitalized patient) and deadly, with a mortality rate of 10%. SBP can be diagnosed by analysis of ascitic fluid obtained by a simple bedside diagnostic paracentesis, a procedure well within the scope of all emergency medicine physicians. Given this, several consensus guidelines recommend that all patients with cirrhosis and ascites admitted to the hospital should undergo abdominal paracentesis at the time of admission in order to rule out SBP (Runyon 2012). Despite general acceptance of these recommendations to providers as “standard care,” adherence has been shown to be poor. The authors of this study set out to determine the effect of the performance of paracentesis on hospitalized adults with cirrhosis and ascites by chart review of a large clinical database (the Nationwide Inpatient Sample, or NIS) with in-hospital mortality as the primary endpoint.

Clinical Question

Does the performance of diagnostic paracentesis on patients admitted to the hospital with cirrhosis and ascites effect in-hospital mortality.

Population

Adult patients (>17 y/o) admitted non-electively to a hospital in the 2011 National Inpatient Sample, with discharge diagnoses of ascites and cirrhosis.

Intervention

Paracentesis during hospital admission, captured by procedure code

Control

No paracentesis performed according to procedure code

Outcomes

Primary: In-hospital mortality length of stay, and total hospitalization cost
Secondary: length of stay (LC), and total hospitalization cost (HC)

Design

Retrospective Chart Review

Primary Results

  • Out of 8,023,590 admissions in the 2011 NIS, 31,614 met inclusion criteria
  • 51% underwent paracentesis

Critical Findings

  • In-Hospital Mortality (Primary Outcome)
    • Patients who did not undergo paracentesis had higher mortality than those who did
    • 8.9% vs 6.3% OR 1.83 (95% CI 1.66-2.02)
  • Secondary Outcomes
    • Early paracentesis (Day 0-1) showed a trend towards reduction in mortality (5.5% vs 7.5%) that did not reach significance
    • Among those diagnosed with SBP, early paracentesis was associated decreased LOS (7.55 vs 11.45 days, P < 0.001) and decreased HC ($61 624 vs $107 484, P < 0.001).

Strengths

  • Large sample size; included 31,614 out of a total sample of 8,023,590 patients

  • Varied clinical settings, including rural, urban-teaching and urban-nonteaching hospital

  • The independent variable, performance of paracentesis was captured by procedure code (54.91), a method that has been previously validated

  • Other measured variables used robust and validated methodology when possible

  • The studies’ findings are in line with previous research and consensus guidelines

Limitations

  • Study was a retrospective chart review and thus, patients may have been missed
  • Chart review/data extraction methods were not well described in the study
  • It is unclear how many chart extractors were used and if the researchers looked at agreement between extractors
  • The study was unable to capture factors that might effect the clinical decision-making about performing or deferring paracentesis. For example paracentesis might be hindered by technical factors, or deferred in the setting of empiric treatment.
  • Using ICD codes is an imperfect measure of many of the variables analyzed. For example it, was not possible to determine patient level characteristics related to patient mortality, including the model of end-stage liver disease score, Child-Pugh score, or laboratory values, which might reflect severity of liver disease
  • The study showed a correlation between paracentesis and lower in-hospital mortality, but by its nature does not clearly show causation.

Author's Conclusions

"Paracentesis is under-utilized among cirrhotic patients presenting with ascites and is associated with decreased in-hospital mortality. These data support the use of paracentesis as a key inpatient quality measure among hospitalized adults with cirrhosis. Future studies are needed to investigate the barriers to paracentesis use on admission.”

Our Conclusions

In this large, retrospective chart review of patients with cirrhosis and ascites who were admitted to the hospital for any reason, performance of diagnostic paracentesis was associated with decreased in-hospital mortality. Although this has been part of “standard care” for some time, in this current study, it occurred in only 51% of patients. As emergency providers we are uniquely capable to perform these procedures, and our choices in the ER will affect clinical course throughout our patient’s admissions.

Potential Impact To Current Practice

Providers should strongly consider a diagnostic paracentesis in all patients with ascites who are being admitted to the hospital.

Bottom Line

When taken in the context of current consensus guideline, as well as the high incidence and mortality of SBP, this paper is strong evidence that performing a diagnostic paracentesis on patients with cirrhotic ascites when they are admitted to the hospital reduces mortality. If you admit a patient with cirrhosis and ascites, perform a diagnostic paracentesis.

Read More

References

Runyon BA. Management of Adult Patients with Ascites Due to Cirrhosis: Update 2012. AASLD Practice Guideline. Link