Understanding What are the complications of massive paracentesis?

October 1, 2025 •

4 min read

While large-volume paracentesis is generally safe and effectively treats severe ascites, it carries roughly a 1% risk of overall complications. A clear understanding of what are the complications of massive paracentesis is critical for anticipating potential risks and ensuring patient safety.

Quick Summary

Massive paracentesis poses several potential risks, including paracentesis-induced circulatory dysfunction (PICD), hemorrhagic complications, infection, and organ perforation. Close monitoring and preventative measures like albumin administration are crucial for managing these adverse events.

Key Points

Paracentesis-Induced Circulatory Dysfunction (PICD): A major systemic risk of large fluid removal, leading to hypotension, renal dysfunction, and faster reaccumulation of ascites.
Hemorrhagic Complications: While rare overall, bleeding complications like abdominal wall hematomas or potentially fatal hemoperitoneum can occur.
Infection Risk: Infection at the puncture site or in the peritoneal fluid (SBP) is a potential, though manageable, complication.
Organ Perforation: The accidental puncturing of internal organs like the bowel or bladder is an extremely rare but serious risk.
Fluid and Electrolyte Shifts: Rapid fluid removal can cause imbalances leading to low blood pressure and hyponatremia.
Preventative Measures: Administering intravenous albumin for volumes over 5 liters helps prevent PICD, while ultrasound guidance reduces bleeding and perforation risks.

What is Massive Paracentesis?

Massive or large-volume paracentesis is a medical procedure used to drain a significant amount of excess fluid (ascites) from the abdominal cavity. This fluid buildup is most commonly associated with advanced liver disease, such as cirrhosis, but can also occur due to other conditions like cancer or heart failure. For patients experiencing symptoms like severe abdominal pain, shortness of breath, or discomfort from the fluid accumulation, massive paracentesis offers rapid and effective relief. However, removing a large volume of fluid, typically more than 5 liters, can trigger significant physiological shifts in the body, leading to specific and potentially serious complications.

Paracentesis-Induced Circulatory Dysfunction (PICD)

Paracentesis-induced circulatory dysfunction (PICD) is a serious complication that can occur after rapid, large-volume paracentesis. It involves a systemic response leading to arterial vasodilation and decreased effective blood volume. This can result in rapid reaccumulation of ascites, hyponatremia (low sodium), renal impairment including hepatorenal syndrome, and hypotension (low blood pressure). To mitigate this risk, intravenous albumin is recommended during large-volume paracentesis (typically over 5 liters) to help restore plasma volume and stabilize circulation.

Hemorrhagic Complications

Hemorrhagic complications, while generally infrequent, can be severe. Patients with advanced liver disease may have a higher risk due to pre-existing clotting issues. Potential bleeding issues range from abdominal wall hematomas at the insertion site to the more serious and potentially fatal hemoperitoneum (bleeding into the peritoneal cavity). Rare complications include pseudoaneurysms at the puncture site. Using ultrasound guidance and carefully selecting the insertion site can help reduce the risk of bleeding.

Infections

The risk of infection exists with any procedure that breaks the skin. Potential infections include spontaneous bacterial peritonitis (SBP), a serious infection of the ascitic fluid, and local infections at the insertion site. Maintaining strict sterile technique during the procedure is crucial for prevention, and monitoring for symptoms like fever and abdominal pain is important for early detection.

Organ Perforation and Other Local Issues

Accidental puncture of internal organs such as the bowel, bladder, or spleen is a rare but serious risk, significantly reduced with ultrasound guidance. Bowel or bladder perforation can lead to infection and may require surgery. Splenic laceration is a risk with insertions in the upper left quadrant, especially with an enlarged spleen. Persistent leakage of ascitic fluid from the puncture site is a common, typically minor issue that may be managed with a small suture.

Comparison of Major Complications


Complication	Primary Mechanism	Key Symptoms	Management/Prevention
Paracentesis-Induced Circulatory Dysfunction (PICD)	Rapid removal of large fluid volume leading to vasodilation and reduced effective blood volume.	Hypotension, rapid reaccumulation of ascites, hyponatremia, renal impairment (hepatorenal syndrome).	Administer intravenous albumin for volumes >5 L; close monitoring post-procedure.
Hemorrhagic Complications	Puncture of a blood vessel in the abdominal wall or peritoneum.	Abdominal wall bruising/hematoma, severe abdominal pain, signs of shock (if hemoperitoneum).	Use of ultrasound guidance; careful site selection; surgical or interventional radiology (IR) for severe cases.
Infection	Seeding of bacteria into the peritoneal fluid or at the insertion site.	Fever, chills, abdominal pain, redness/swelling at the puncture site.	Strict sterile technique; post-procedural antibiotics if indicated.
Organ Perforation	Accidental puncture of abdominal organs (e.g., bowel, bladder, spleen).	Severe pain, signs of infection, peritonitis.	Use of ultrasound guidance; surgical repair if severe.

Key Factors to Mitigate Risks

To minimize the risks associated with massive paracentesis, healthcare providers follow several key practices:

Albumin Administration: For large-volume paracentesis (more than 5 liters), intravenous albumin is administered to prevent PICD by maintaining plasma volume.
Ultrasound Guidance: The use of ultrasound to guide the needle insertion significantly reduces the risk of bleeding and organ perforation by allowing visualization of underlying structures.
Careful Site Selection: The puncture site is chosen carefully, typically away from old surgical scars and visible blood vessels, to avoid injury to critical structures.
Monitoring: Close monitoring of the patient's vital signs and overall condition during and after the procedure is crucial to detect complications early.
Coagulation Assessment: While routine transfusions are not recommended based on standard tests, patient history and clinical assessment are important for evaluating bleeding risk.

Conclusion

Massive paracentesis remains an invaluable and effective procedure for providing symptomatic relief for patients with severe ascites. While the procedure is generally safe, understanding what are the complications of massive paracentesis is essential for all involved. Key risks include the development of Paracentesis-Induced Circulatory Dysfunction (PICD), bleeding, infection, and, rarely, organ perforation. Proactive measures, such as using ultrasound guidance and administering albumin, have significantly reduced the incidence of serious adverse events. Despite these risks, with proper technique and management, paracentesis can greatly improve a patient's quality of life.

Visit the National Institutes of Health for more information on paracentesis.

Frequently Asked Questions

PICD is a complication that can occur after large-volume paracentesis, where the body's circulatory system overreacts to the rapid fluid shift. It can lead to systemic vasodilation, causing low blood pressure (hypotension), kidney impairment, and rapid reaccumulation of ascites.

Doctors can prevent complications by using ultrasound guidance for needle insertion, administering intravenous albumin for drainage over 5 liters, and carefully selecting the puncture site to avoid blood vessels and organs. Close monitoring during and after the procedure is also essential.

Significant bleeding is a rare complication, but it is possible. Risks include hematomas at the puncture site and, very rarely, severe internal bleeding (hemoperitoneum). Bleeding risk is not reliably predicted by standard coagulation tests in patients with liver disease, though ultrasound guidance helps minimize this risk.

Signs of an infection include fever, chills, redness, swelling, or increasing pain at the puncture site. If these symptoms occur, a healthcare provider should be contacted immediately.

Persistent fluid leakage, while not uncommon, is usually minor and often resolves on its own. In some cases, it can be stopped with a single skin suture. It is caused by the draining of ascitic fluid from the needle insertion tract after the procedure.

Albumin is given intravenously after removing more than 5 liters of fluid to prevent PICD. It helps to expand the plasma volume and stabilize blood pressure, preventing the rapid reaccumulation of ascites and reducing the risk of renal complications and hyponatremia.

The risk of puncturing internal organs like the bowel or bladder is extremely low, especially with the use of ultrasound guidance. If it does occur, it is a serious complication that may require surgery.