The safety and feasibility of large volume paracentesis performed by an experienced nurse practitioner.

Due to time constraints, fewer physicians are performing large volume paracentesis (LVP) resulting in a longer wait time and more emergency department (ED) and hospital admissions. At our institution, after initial supervision, a certified nurse practitioner (NP) has independently performed LVP in a dedicated cirrhosis clinic. The purpose of our study was to evaluate the feasibility and safety of LVP performed by a NP. A retrospective review of patients undergoing LVP between January 2003 and May 2007 was performed. Baseline patient information and the practitioner performing LVP (physician or NP) were recorded. Complications including post paracentesis hypotension, bleeding, local leakage of ascitic fluid, infection, perforation, and death were compared between the two groups. A total of 245 procedures in 41 patients were performed by a single NP, and 244 in 43 patients by physicians. Baseline characteristics of patients undergoing LVP were similar in two groups. Alcohol was the most common etiology of cirrhosis (46% in NP and 51% in physician group) followed by a combination of alcohol plus HCV (37% in NP and 28% in physician group). There was similar distribution of Childs class B and C patients in the two groups, as well as average MELD score. Total volume of ascites removed, number of needle attempts, and complications including post paracentesis hypotension, local leakage of ascitic fluid, bleeding, infection, and death were not statistically different between the two groups. Our study shows no difference between physician and NP performance of LVP and complication rates. LVP performed by a NP is feasible and has acceptable rate of complications.

Hepatic hydrothorax: current concepts of pathophysiology and treatment options.

Pleural effusions develop in 6-10% of patients with end-stage liver disease. Although, commonly seen in conjunction with ascites, isolated hepatic hydrothorax can occur in a small number of patients with cirrhosis. Refractory hepatic hydrothorax particularly poses a challenging therapeutic dilemma as treatment options are limited at best in these patients. Current patho-physiologic understanding of this disorder, as a cause, points towards the presence of diaphragmatic defects responsible for the shift of fluid from the peritoneal to the pleural cavity. When sodium restriction and diuretic treatment fail, liver transplantation remains the most definitive therapy in these refractory cases. However, transjugular intrahepatic porto-systemic shunt (TIPS), or video-assisted thoracoscopic (VATS) repair of the diaphragmatic defects (with or without pleurodesis) are effective strategies in those who are not transplant candidates or those awaiting organ availability. Hepatic hydrothorax, especially when refractory to medical treatment, poses a challenging management dilemma. An early recognition and familiarity with available treatment modalities is crucial to effectively manage this exigent complication of cirrhosis.