Does peritonitis have to be drained?

[Matthew89]

Hello! Just wanted to ask anyone who is familiar with ascitis? The patient has massive ascites per CT scan. But the doc doesn't want to drain because she said once you tap you have to continuously tap the patient which might expose them to infection. But my question is the pt is abdominally breathing and another MD thinks its peritonitis. Does peritonitis have to be drained?

[traumaRUs, MSN, APRN]

Ascites needs to be drained and yes it often recurs. If done sterilely the risk is minimal. I have pts with end stage liver disease that get a paracentesis weekly and some of my pts high weekly high volume (>10L) weekly. 

[nursej22, MSN, RN]

Spontaneous peritonitis can occur with ascites. I've seen patients who had and indwelling catheter sort of like a PEG, that got drained regularly. 

Ascites usually occurs in end stage liver failure, so it's usually a comfort measure. Dying of liver failure, gasping for breathe and suffering from abdominal pain is horrible. Throw in having loose, frequent stooling from lactulose to add to the misery. 

[Matthew89]

Have you ever heard this? The doctor doesn't want to drain massive ascites with possible peritonitis. Because they are afraid of recurring drainage and risk for infection. 

It was ascites from low albumin. Ckd patient. 

[NRSKarenRN, BSN, RN]

Home care agencies RN can even provide ascites drainage at home using Pleurex catheter for those with recurrent ascites .  Please see Traumas response as Nephrology NP.  Patient needs to be informed of options and third opinion if necessary.  Thanks for advocating for your patient.

Paracentesis

[Matthew89]

Thank you for all the responses. So all ascites needs to be drained? I don't understand the doctor. Why they won't drain especially if they think there is peritonitis. I'm not sure if this is something new or if anyone has an idea about this. I'm afraid that a bad infection will happen. 

[nursej22, MSN, RN]

No, ascites does not need to be drained; it is often done as a comfort measure (allow for easier breathing). If the patient can tolerate doing without, then it may not be necessary. It can result in significant volume loss and electrolyte shifts. It is sometimes treated with albumin and or spironolactone/furosemide. 

Peritonitis refers to inflammation, often infection, in the peritoneum. It is usually treated with antibiotics and addressing the underlying cause, such as a ruptured appendix or perf'd bowel. 

Infection is always a concern, but I don't see that this patient is at elevated risk, unless they have an impaired immune system. 

[Matthew89]

Wow you're are very smart. I tried researching for a rationale but it always leads me to liver cirrhosis. So if ascites is present and they suspect peritonitis, they don't have to drain it? I was just afraid that my patient would deteriorate if they didn't culture or drain it. Patient said ascites has been there for a year. Tried albumin and dialysis with no success. There was not really any notes that I could read so I was not sure. 

[NRSKarenRN, BSN, RN]

Another clue: ascites x 1 year -- some physicians will treat  with IV antibiotics first to treat suspected peritonitis /sepsis prior to any paracentesis consideration for long term ascites, only perform abdominal tap if shortness of breath (SOB) does not respond to spironolactone/albumin diuretics and worsens with acute distress.  Keep reading and asking questions of physicians to understand treatment protocal for this specific patient.

Ascites: Nursing Diagnoses, Care Plans, Assessment & Intervention

Ascites What Is It, Causes, Appearance, Treatment, and More

Nephrogenic Ascites: An Unusual Culprit of Refractory Ascites in a Hemodialysis Patient—A Case Report and Review of Literature

[Matthew89]

I appreciate your response. Thank you also for the literature and the imparted knowledge. I'm new to this and want to learn. I was just worried because the ascites was there for a year and they are currently treating with IV abx - Zosyn. I didn't want my patient to become septic.  It's difficult without much notes or doctors explaining since we work in a small hospital. But I thank everyone for answering my questions. Everyone is very knowledgeable. Will read up on the literature. Thank you. ❤️

[JBMmom, MSN, NP]

Matthew89 said:

Wow you're are very smart.

You're smart, too! You had a concern for your patient, you did some research and you came this this site where there are nurses with a variety of backgrounds and experience and you asked good questions and followed up in the conversation. Nurses here have the luxury of time to answer, we're not coworkers on a busy floor trying to get through a day while understaffed. You're going to be a great nurse for your patients with your willingness to research and learn in order to provide them the best care. Good for you and keep up your good work!

[vampiregirl, BSN, RN]

NRSKarenRN said:

Home care agencies RN can even provide ascites drainage at home using Pleurex catheter for those with recurrent ascites .  

Paracentesis

Aspira drain is another system that can be used for recurrent ascites (as well as recurrent pleural effusions). Typically starts out with Home Care upon hospital discharge but I have had family members who have been trained to perform this procedure as needed to address dyspnea. 

https://www.myaspira.com

Home drainage systems can remove up to 14L a week (2 L daily) with ascites if the physician orders this and the patient can tolerate. 

Thank you for advocating for this patient. There are several options available once patient goals are defined. Most of the patients I've worked with have had at least one or two procedures paracentesis procedures performed in IR prior to drain placement to make sure the ascites is recurrent in the same area. With IR they can make adjustments to where they place the catheter but with pleurx and Aspira, the "pockets" of ascites need to be localized to one area so that catheter is effective at draining the fluid.