Large Volume Paracentesis Protocol

Cirrhotic patients with large quantities of ascites may benefit from large volume paracentesis. This can be done as an outpatient in the Endoscopy Suite on PH 12 or as an in patient at the bedside. The Liver Transplant team uses the Quick Tap Kit (available in the Endoscopy Suite). The resident assisting with the procedure should order from pharmacy at least 4 bottles of 25% albumin to be administered during the procedure. The patient is given albumin according to the following guidelines

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Dose of Albumin Following Paracentesis of Cirrhotic Ascites in Adult Patients

*Individualize albumin doses in patients with estimated or measured

CrCl <30 mL/min.

Mucomyst (N-acetylcysteine) Administration for Tylenol Over Dose

Mucomyst should be administered orally or via NGT for Tylenol over doses. The patient needs a loading dose of 140 mg/kg. If tolerated, patient should receive 17doses q4 hours at a dose of 70 mg/kg. Patients can be premedicated with Intravenous Zofran. If vomiting results then intravenous administration of Mucomyst is recommended. An attending Physician should be consulted if Intravenous Mucomyst is indicated. It has currently not been approved fointravenous administration by the FDA.

Other indications for IV dosing include:

*Intolerance to oral Mucomyst

*Coingestion with potential for morbidity and mortality necessitating ongoing gastrointestinal decontamination

*Gastrointestinal bleeding

*Gastrointestinal obstruction

*Medical conditions precluding oral administration

*Encephalopathy

*Neonatal Tylenol toxicity from maternal overdose

Procedure for IV administration of Mucomyst:

1. Obtain informed consent

2. Patient should be admitted to the ICU

3. Intravenous Benadryl and Hydrocortisone must be at the bedside.

4. Determine appropriate dose of Mucomyst ( see Appendix B)

5. Oral Mucomyst should be diluted to a 3% or 5% solution in D5W

3% solution is the preferred dilution, but 5% can be used when fluid status is a concern. (Volume overload, renal failure)

6. An in-line 0.22 Millipore filter should be used during intravenous infusion.

7. Loading dose of 140 mg/kg should be infused intravenously over 60 minutes.

8. Maintenance dose of 70 mg/kg should be initiated 4 hours after administration of loading dose and every four hours until a total of 17 maintenance doses are given this includes any oral and intravenous doses.. Each maintenance dose should be infused over 60 minutes.

9. Patients can be switched to oral administration at any time. If switched to oral administration the duration of therapy should be continued for 72 hours.

Management of Adverse Reactions to Intravenous

A Flushing

-continue Mucomyst if necessary

-consider slowing down infusion rate

-no treatment warrented

B. Urticaria

-reassess need for Mucomyst

-continue meds if necessary

-administer benadryl 1 mg/kg IV (max50mg)

C. Angioedema

-discontinue infusion

-treat symptomatically

-Benadryl 50mg IV

-Reassess need for IV Mucomyst

-For life-threatening reactions, consider:

• decreasing infusion rate

• Cimetadine 5mg/kg IV (maximum dose 300mg)

• Ephedrine 0.5mg/kg orally (maximum dose 25mg)

If no symptoms after 1 hour restart infusion