performing paracentesis in the ER?

[Painter1]

what would u do?

50-something yo male with cirrhosis and ascities had 10+ liters of fluid removed by GI as outpatient. he presented at night a few hours later for "leakage" of fluid from paracentesis site. no other complaints. well-appearing, vitals wnl. nice steady leak from the site.

what u do? what's standard of care?

do u attemp to stop leak with a suture or steristrip and send patient home?

or you call gi and turns out they tell you to do another paracentesis, remove 5 liters, infuse him with albumin then discharge him?

do you admit under observation and have IR or GI do whatever they want the next day?

i'll share more once i hear some feedback.

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[WilcoWorld]

Since it's a gastroenterological complication of a gastroenterological procedure done for a gastroenterological disease I'd probably do what Gastroenterology recommended - except for putting another hole in an already leaking belly.

I'm not convinced that repeated instrumentation (while it might decrease intraperitoneal pressure and stop the drainage) would decrease the overall complication (mainly infection or hypovolemia) rate in this setting. If GI wants to come in and do that it's fine by me - it's their patient - but I would probably leave well-enough alone unless the patient became unstable (at which point it stopped being "well-enough").

 

[Apollyon]

GI did it and this is a post procedure complication. They get a call. That is not negotiable. It depends on what they say. Options are send home or admit. If admit, them or someone else (hospitalist/IM residents). GI's name is all over the chart.

Now, if he had 10L taken off, I would be very wary of taking off another 5L. For one, if they didn't remove it earlier in the day, I can't see doing it now. For the other, if he had 5L accumulate in 12 hours, that is indicative of something else acutely happening.

What does NOT happen is me putting on a steri-strip and sending them home without GI involvement.

 

[Painter1]

So GI is called. GI requesting ER staff do repeat paracentesis and infuse patient with albumin then discharge the patient.

I didn't feel there was an indication for ME to do a paracentesis. I explained that there was no indication emergently and that he was welcomed to come to the ED and do it himself.

It just didn't ring right with me. they remove more than 10 liters, then he comes in with a complication of their procedure and they want us to drain him some more, infuse him with albumin and discharge him?!

the worst part is, the gi guy was irate, he was furious that we wouldn't do it. he claimed this was customary he was baffled that we were refusing to do it. he kept asking, "arent u certified to do this as an er doctor?!" he felt so strong about it, that he threatened to report the case to the medical director of the hospital. he finally exploded yelling to put a colostomy bag over the site to send him home with f/u with them.

what u do then?

 

[SoCuteMD]

GI gets a call and is asked to come down and fix their complication. We do not do large volume paracenteses in our emergency department, due to staffing requirements and interference with patient flow. Large volume para = admit to medicine with GI consult. I probably wouldn't be willing to sew it up. There is a reason this is not standard practice after a para - these patients bleed and they get infected. Either one of those could happen if I attempted to stitch it.

So GI's options in this case are:
- Come down and fix the leaking
- Consult on the patient up on the floor

 

[deleted6669]

I have never taken off more than 6L at once. per rosen and barkin>9L has a much higher complication rate. I actually checked this a few weeks ago when someone asked me to take off more- I took off 6 and told them if they wanted more than that they could come in and do it themselves or do it in their clinic monday morning( it was of course saturday night.) the guy was short of breath due to massive ascites from etoh liver disease, and he was a big dude, but I'm not taking >9 off anyone...and he did fine with 6. felt much better and was d/c home to f/u monday am.

 

[deleted109597]

Diagnostic paracentesis is an emergent procedure.
Therapeutic is not.
Just like I won't transfuse and discharge the sicklers, I won't drain and discharge the cirrhotics. Sorry, but I don't have time or bed space for that.

 

[docB]

Wow! That's a tough case. I have tapped plenty of bellies, given albumin and discharged (although not recently as we tend to admit most of our ascites patients where I am now for other reasons).

One thing about EM and dealing with consultants is you have to pick your battles. I might be willing to do as the GI wants in this instance. The main thing I would be concerned about would be the question of why the guy is leaking. Is he not clotting? Did he reaccumulate faster than expected (as previously mentioned)? Did they stick something they shouldn't have (is that urine coming out rather than ascites)? if I was pretty sure about the rest I might do the repeat tap, infuse and dc.

The big thing I hear here is that the OP got that uncomfortable vibe. You've gotta pay attention to that.

So some other strategies would be to infuse the albumin and have the patient follow up without a repeat tap. Or, depending on what time it is, sitting on the patient while they get their labs, infusion and then discharging them with instructions to go directly to the GI doc.

Those are options. The safest approach would be to admit and have GI see in house.

How high is the rate of infection with a leak? If fluid is coming out is it really that high? I could see how it might be. I would not stitch it. That would amost certainly be a mess.

 

[Painter1]

Wow! That's a tough case. I have tapped plenty of bellies, given albumin and discharged (although not recently as we tend to admit most of our ascites patients where I am now for other reasons).

One thing about EM and dealing with consultants is you have to pick your battles. I might be willing to do as the GI wants in this instance. The main thing I would be concerned about would be the question of why the guy is leaking. Is he not clotting? Did he reaccumulate faster than expected (as previously mentioned)? Did they stick something they shouldn't have (is that urine coming out rather than ascites)? if I was pretty sure about the rest I might do the repeat tap, infuse and dc.

The big thing I hear here is that the OP got that uncomfortable vibe. You've gotta pay attention to that.

So some other strategies would be to infuse the albumin and have the patient follow up without a repeat tap. Or, depending on what time it is, sitting on the patient while they get their labs, infusion and then discharging them with instructions to go directly to the GI doc.

Those are options. The safest approach would be to admit and have GI see in house.

How high is the rate of infection with a leak? If fluid is coming out is it really that high? I could see how it might be. I would not stitch it. That would amost certainly be a mess.

so i actually called our chairman point blank to see what he suggested. the guy was being threatening so i needed to escalate this myself.

the verdict was that what he requested i do was not standard of care. the chairman was clear as mud how he felt about the case and assured me that it would be inappropriate for me to perform the tap, infuse him with albumin and dishcarge him. that is something that we should not be doing in the ED.

 

[Apollyon]

so i actually called our chairman point blank to see what he suggested. the guy was being threatening so i needed to escalate this myself.

the verdict was that what he requested i do was not standard of care. the chairman was clear as mud how he felt about the case and assured me that it would be inappropriate for me to perform the tap, infuse him with albumin and dishcarge him. that is something that we should not be doing in the ED.

"As clear as mud" means "not clear". Do you mean to say your chair was very clear? That seems to be the thrust of your post, or at least what I got from it. Good job going up the chain, and your chair sounds stand-up.

 

[NinerNiner999]

Ironically, it was suggested to us in residency to NEVER be credentialed for paracentesis. The reason they gave was that nothing good ever comes from a complication from this procedure. In the handful of times I have encountered a patient who actually needed an emergent paracentesis, I have always been able to have IR take care of this without any question because, simply, I am unable to perform procedures I am not credentialed to perform...

 

[deleted6669]

Ironically, it was suggested to us in residency to NEVER be credentialed for paracentesis. The reason they gave was that nothing good ever comes from a complication from this procedure. In the handful of times I have encountered a patient who actually needed an emergent paracentesis, I have always been able to have IR take care of this without any question because, simply, I am unable to perform procedures I am not credentialed to perform...

that doesn't cut it in a rural facility that doesn't have IR or GI coverage....I would feel silly sending someone on a 2 hr transfer for an easy procedure which they would likely be discharged home after receiving(followed by a 2 hr drive home).

 

[xaelia]

I have done both diagnostic and therapeutic paracentesis in the Emergency Department, and I do agree that therapeutic paracentesis is not an appropriate Emergency Department procedure. The potential complications of large-volume paracentesis are sufficient that I would prefer not to perform a procedure that can be performed on a relatively urgent outpatient basis or left to the admitting team (I am pretty certain my IM colleagues receive training in paracentesis). This consultant may choose to see his patient the next day in clinic, come in to the Emergency Department to manage his patient, or arrange for his patient to be admitted and consult.

While it is a relatively simple procedure, it is time consuming and yet again, what is best for a single patient is not always the most prudent allocation of patient care resources in an Emergency Department setting.

 

[southerndoc]

I do not do paracentesis in the ER unless it's diagnostic (r/o SBP) or the patient is in extremis (such as persistent hypoxemia refractory to oxygen).

Otherwise, if it needs draining, they get admitted to the hospitalist service and IR can do it. I've sent quite a few people home with appointments to come back the next day for IR to do it.

 

[Painter1]

"As clear as mud" means "not clear". Do you mean to say your chair was very clear? That seems to be the thrust of your post, or at least what I got from it. Good job going up the chain, and your chair sounds stand-up.

sorry for the confusion. he was very clear.

 

[Painter1]

Ironically, it was suggested to us in residency to NEVER be credentialed for paracentesis. The reason they gave was that nothing good ever comes from a complication from this procedure. In the handful of times I have encountered a patient who actually needed an emergent paracentesis, I have always been able to have IR take care of this without any question because, simply, I am unable to perform procedures I am not credentialed to perform...

i thought that by getting credentialed as an attending in the ER you get credentialed to do such procedures, including paracentesis. anyway, i would only do it if i suspect SBP or if the patient is in signficant respiratory distress. the patient ended up getting admitted. i had full support from all the attendings i work with. none of them would've done it.

 

[kungfufishing]

I will perform diagnostic paracentesis - seems like in the folks who need it the procedure takes about as long as a blood draw -but not therapeutic.

 

[docB]

i thought that by getting credentialed as an attending in the ER you get credentialed to do such procedures, including paracentesis. anyway, i would only do it if i suspect SBP or if the patient is in signficant respiratory distress. the patient ended up getting admitted. i had full support from all the attendings i work with. none of them would've done it.

There's also a lot to be said about the community standard. If no one else in your area would have done this then it's a lot harder to go out on a limb for it/it means the consultant is being unreasonable by demanding it.

 

[docB]

This also brings up a good point about privileging. Every doc has a specific "Delineation of Privileges" on file with the hospital. Most EPs are credentialed to do paracentesis but you can't know for sure unless you look (or remember from when you filled it out). You have to be careful because a lot of hospitals have little oddities in their usual DOPs such as credentialing you to do burr holes for example or not allowing sedation with certain drugs like Propofol.

 

[Laryngophed]

This also brings up a good point about privileging. Every doc has a specific "Delineation of Privileges" on file with the hospital. Most EPs are credentialed to do paracentesis but you can't know for sure unless you look (or remember from when you filled it out). You have to be careful because a lot of hospitals have little oddities in their usual DOPs such as credentialing you to do burr holes for example or not allowing sedation with certain drugs like Propofol.

Slightly off-topic but the number of people that have to sign off on a doc prior to that doc being able to do their job at a given hospital is mind-boggling. It seems like everyone in the hospital, from the 3rd shift, weekend security guy to the fellas at the top has to put their John Hancock on something before you can get to work.

 

[docB]

Slightly off-topic but the number of people that have to sign off on a doc prior to that doc being able to do their job at a given hospital is mind-boggling. It seems like everyone in the hospital, from the 3rd shift, weekend security guy to the fellas at the top has to put their John Hancock on something before you can get to work.

Yeah, some hospitals have tons of infighting about everyone's little fiefdoms like ultrasound, sedation, surgical procedures like I&Ds, ortho reductions, etc. Other places view the ED like this cave they're afraid of and never want to venture into so they just leave us alone. Most places ar a mix of the two where some other departments give us static and some don't.