Essential to identify the likely pathology. Most cancer patients with ascites have diffuse peritoneal cancer (albumin rich exudates with serum-ascites albumin gradient (SAAG) <11g/L). Some have massive liver metastases or chronic liver problems causing portal hypertension (albumin poor transudate with SAAG >11g/L). Consider portal vein thrombus.

Consider if prognosis likely to be months. Ascites from liver cirrhosis, nephrotic syndrome or massive liver metastases (SAAG >11g/L – see reference if unsure) can respond well to salt restriction and diuretics (discuss with GI/hepatology). However, whatever the cause, if ascites is not tense, a therapeutic challenge of spironolactone, starting at 50mg and titrating upwards, weekly, to a maximum of 300mg, with electrolyte monitoring, may be tried. Furosemide 20-40mg can also be added if condition allows, particularly if K retention precludes higher doses of spironolactone. If effective, a daily weight loss of 0.5 – 1kg/day and symptomatic benefit would be expected.

Diuretics should be stopped if significant drop inserum sodium, rise in serum creatinine, rise in potassium or if not effective. 

This is generally a safe procedure. Haemoperitoneum, bowel entry and sepsis are rare. Frequently drainage of only 1-2L results in good palliation and might be satisfactory if that is the main purpose of drainage.  Long hospital admissions are not good palliation – aim for completion of drainage in less than 4 hours. Drainage results in relief of early satiety, vomiting, dyspnoea, dyspepsia, uncomfortable tense abdomen in the majority (particularly gynaecological malignancies), but may increase rate of deterioration in some cancers (upper GI, pancreas, GI with poor performance status) or increase pain in others (diffuse peritoneal disease e.g. ovary).  It is the reduction of pressure and not volume that eases symptoms.  

• Written information: if patient has not already been given ascites patient information leaflet (PIL) then give this to patient.
• Written consent: ensure patient is happy to go ahead. Sign consent form and document discussion of risks, benefits and alternatives in notes 
• Assessment of patient: confirm patient’s condition is stable and paracentesis still the right procedure.
• Ultrasound: Always advisable. Ultrasound should be arranged as soon as admission is planned to confirm the diagnosis and mark the optimum site for paracentesis. Patient can be taken straight to ultrasound on arrival, as soon as request is on TRAK. N.B: ovarian cancer patients have a protected USS slot (phone the department). 
• Baseline bloods: including U+E, coagulation, albumin, protein and FBC. These bloods should be repeated urgently on the day if they have not been done within 2 days of admission (eg GP or clinic). If coagulation is deranged or INR >1.5 Correct coagulation/ consider delay of drainage. 
• With-hold diuretics and anticoagulants during drainage. Re-start on discharge. Low molecular weight heparin should be omitted the day before drainage. 

• Consent: Confirm written consent done for the procedure, given patient information sheet and document discussion of options and risks in notes. 
• Ensure at least 48 hours since systemic anti-cancer therapy (SACT) administration. 
• Place patient in position in which they were scanned.
  • Using personal protective equipment (apron, gloves (and mask if recent SACT), a Bonano suprapubic catheter should be inserted under aseptic conditions into flank at the marked spot, with local anaesthetic. If marked spot appears to lie over important anatomical landmark e.g. inferior epigastric arteries, then drain should be inserted in a preferable location.
  • Drain should be left on free drainage unless contraindicated (renal dysfunction, very frail, some GI/HPB etc).
  • Nursing obs. every 1L or every 15 minutes for first hour. Hourly or every 1 litre thereafter if stable.
  • Advise patient to move around during drainage.
  • The aim is to remove fluid in 1 to 4 hours if patient fit and tolerates this. 
• Routine medical review daily or after 5L drained then after each additional 2L to assess timing of removal of drain. Drain should be removed if 5L have been drained and/or symptoms are relieved or if drain is slowing. Ideally all drains should be removed within 24-48 hours even if there still appears to be ascites present.
• Additional medical review if BP drop of >20 mmHg, signs of dehydration, deterioration of symptoms or any other clinical concern about patient’s condition. Consider drain removal if symptoms are relieved, drain is slowing, or condition is deteriorating. Consider IV fluids (up to 1L then review) and/or clamp for 2-4 hours between drainages of up to 1L. If drain to be kept in, nursing obs. at least every 1L.  
• Remove drain as soon as drainage slows on free drainage with patient moving around using PPE (including gloves, apron and eye protection goggles against spray on removal. Purple gloves to be worn if patient within 7 days of receiving SACT). Ascites can reaccumulate up to 2L/day. Aim for drain removal within 24-48 hrs.  Consultant review if drain in over 48 hours.  
• After removal ask patient to lie on other side initially for 15 minutes. If leakage at drainage site, try flexible collodion and/or suturing. Occasionally, if persistent leakage, and after medical review, a stoma bag may be applied for a few days only. Watch for signs of hypotension, confusion and sepsis post drainage. 

Can be considered if frequent recurrent drains are required and life expectancy > 3 months and patient is not any cancer treatment that will stop re-accumulation. They have been most effective with breast and ovarian cancers and are least effective with GI cancers. They are contraindicated if haemorrhagic ascites, ascitic protein >4.5 g/L, loculated ascites, portal hypertension, coagulation disorder, renal or cardiac failure. Complications include sepsis, DIC, tumour emboli, pulmonary embolus and pulmonary oedema.

Process of arranging Pleurex drain: 

• Check that CAU have pleurex drain in stock. Then request on TRAK (insertion tunnelled drain abdomen) 
• Liaise with interventional radiology for a date. 
• Once date known, liaise with company who supply pleurex (gynae CNS have contact details), whom will arrange training with patients community nurses on the management of drains. 
• Book bed in CAU. 
• Arrange pre-procedure bloods to be done at GP. 
• Patient will be admitted to CAU on the day of procedure. 
• Ensure the drain goes with the patient for procedure. 
• Patient returns to CAU for recovery. 
• If patient is on SACT or starts SACT with drain in then ensure district nurses are informed of appropriate precautions, as per agreed guidance and using standard letter. 

• Palliative ascitic drainage is usually safe but can result in deterioration of some patients, particularly upper GI/ pancreas or patients of poor performance status. These patients will need carefully assessed before and during procedure and often require slow/cautious drainage. Discuss with patient’s own team if concerns.  If ascites might be due to chronic liver disease (eg patients with cirrhosis) then ascitic drain is not always indicated – discuss with patient’s consultant if unsure. 
• Palliative ascitic drainage should take less than 4 hours if at all possible and only rarely as long as 48 hours. 
• Prior to/on arrival make sure patient ultrasound request has been booked on TRAK. 
• On arrival take bloods urgently (if not done within 48 hours or if any clinical concerns) or review recent bloods on TRAK. 
• Send patient directly to ultrasound (without waiting to be called) between 9-12.30 am and 1.30 to 4pm. 
• Take baseline NEWS score and assess if patient has had prior problems with drainage. 
• Ensure patient has been given patient information sheet on ascitic drainage.
• Ensure catheter and sterile equipment is available. Assist medical staff for procedure as needed.  Purple gloves to be worn if patient within 7 days of receiving SACT (e.g. chemotherapy). 
• Ensure adequate consent taken and patient supported through procedure. 
• Ensure working IV access is available prior to procedure. 
• Leave on free drainage unless otherwise specified. Seek clarification from medical team if any concerns about speed of drainage for a particular patient (see guidance notes 3-5).  
• NEWS to be taken every 1 litre ascites drained or every 15 minutes for first hour, then hourly. 
• Ensure medical staff review daily (inpatients) or after 5 litres (inpatients and day cases) to consider drain removal, or before if drainage is slowing or concerns about patient. If drain is staying in, ask daytime medical staff to review every 2 L drained thereafter to assess condition and consider drain removal.  
• If patient is being drained overnight and is very well with stable nursing obs then medical review to assess drain removal can be deferred to first thing the following morning. 
• If BP drops by more than 20 mmHg, NEWS deteriorates by 2 or more or increases to ≥ 4, signs of confusion or dehydration or patient reports new/deteriorating symptoms, clamp the drain and call medical staff to review patient whether during the day or night to consider drain removal/ iv fluids/ drain clamping. 
• Clamp the drain and start IV sodium chloride 0.9% 500ml over one hour if sudden deterioration. Call medical staff. 
• Remove drain once symptoms are relieved – do not wait for drain always to be ‘dry’. Ensure use of protective clothing, including gloves, apron and eye protection goggles against spray on removal.  Purple gloves to be worn if patient within 7 days of receiving SACT (e.g. chemotherapy). 
• Ensure drain removed within 48 hours and preferably within 24 hours.  Consultant review if drain present for over 48 hours.   
• After drain removal ask patient to lie on opposite side to drain for 15 minutes.  If leakage then try flexible collodion, and pressure dressing.  If leakage persists then suture. Occasionally attach stoma bag and ensure DN review within 24-48 hours. Advise patient re PPE if patient within 7 days of SACT. 
• Ask patient to report any signs of infection (confusion, temperature, pain) over next 48-72 hours directly to ward.