76

DEXTRAN 70 AND OTHER PLASMA EXPANDERS

The use of synthetic plasma expanders with large-volume paracentesis has also been

explored in patients with refractory ascites.

77 Gines et al.

78 studied patients with

ascites refractory to diuretic therapy, who required paracentesis. More patients

treated with dextran 70 (34.4%) or polygeline (37.8%) experienced PICD than those

receiving albumin (18.5%).

78 Hydroxyethyl starch, an effective colloid agent for

intravascular volume expansion, should not be used in patients with cirrhosis,

because repeated administration in this population has been reported to accumulate in

the hepatocytes, causing severe portal hypertension and acute liver failure.

79

R.W. should be given 50 g of 25% albumin administered at a rate of 3 mL/minute,

for the 6 L of ascitic fluid removed. Albumin 25% infusion is preferred because 5%

solution has fivefold the sodium load.

38 More rapid administration than 3 mL/minute

in hypoproteinemic patients can cause circulatory overload and pulmonary edema.

R.W. should be monitored for anaphylactic reactions (rare), hypotension,

hypertension, and signs of pulmonary edema.

80–82

Alternative Therapy

CASE 25-1, QUESTION 11: What alternative treatments are available for management of refractory

ascites? How would these alternatives be applied in R.W.’s case?

TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT

Transjugular intrahepatic portosystemic shunt (TIPS) is another option for patients

who are refractory to the pharmacologic interventions described previously. It is a

nonsurgical technique for establishing a shunt in patients with portal hypertension

(Fig. 25-2).

83 The TIPS procedure involves opening a conduit between the hepatic

vein and the intrahepatic segment of the portal vein with an expandable metal stent

placed during an angiographic procedure. This low-resistance channel allows blood

to return to the systemic circulation and reduces portal pressure. In addition, TIPS

may improve urinary sodium excretion. The major complications of TIPS include

severe encephalopathy and shunt occlusion. Hepatic encephalopathy (see Case 25-3)

occurs in approximately 20% of patients after TIPS.

83 Because of poor prognosis,

liver transplantation should be considered for appropriate candidates refractory to

pharmacologic treatment and/or shunt placement.

38 Selection of surgical shunt

procedures may include evaluation of liver transplantation candidacy because some

procedures may complicate the feasibility of a future liver transplantation procedure.

Figure 25-2 Transjugular intrahepatic portosystemic shunt (TIPS). A stent is inserted via catheter to the portal

vein to divert blood flow and reduce portal hypertension. (Adapted with permission from Smeltzer SC, Bare BG.

Textbook of Medical-Surgical Nursing. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2000.)

In a small randomized study evaluating patients with cirrhosis and refractory

ascites,

84

the probability of survival without liver transplantation was 41% at 1 year

and 26% at 2 years in the TIPS group, as compared with 35% and 30%, respectively,

in the paracentesis group (not significant [NS]). Recurrence of ascites and

development of hepatorenal syndrome (49% and 9%, respectively) were lower in the

TIPS group compared with the paracentesis group (83% and 31%, respectively; p =

0.003 and p = 0.03), whereas the frequency of severe hepatic encephalopathy was

greater in the TIPS group (p = 0.03). The calculated costs of procedures performed

per patient in the TIPS group were 103% greater than those in the paracentesis and

albumin group.

84 Salerno et al.

85 conducted a meta-analysis of cirrhotic patients with

refractory ascites and found that transplant-free survival was higher in the TIPS

group (38.1% vs. 28.7% at 3 years; p = 0.035), and the recurrence of ascites was

lower (42% vs. 89%; p < 0.0001) than in the large-volume paracentesis group. The

average number of hepatic encephalopathy episodes was significantly higher in the

TIPS group (p = 0.006). However, the probability of developing the first episode of

hepatic encephalopathy was similar between the groups (p = 0.19).