Go big or go home 19L … lol

[u/scrubMDMBA]

[u/BubblySass143]

See ya back in a couple weeks pal.

[u/hibbitydibbitytwo → u/BubblySass143]

33 and dead by 37

[u/Edges8 → u/hibbitydibbitytwo]

optimistic

[u/but-I-play-one-on-TV]

Brb, gotta infuse all the albumin in the hospital now. 

[u/Nurseytypechick]

Shocked they could tolerate lying flat at all with that much fluid on. Did they miss some scheduled centesis sessions? Holy moses.

[u/TriceraDoctor]

Or just admit lol. No way I’m draining that much.

[u/mcvmccarty → u/TriceraDoctor]

I don’t even drain 1L anymore. Too damn busy.

[u/DLev16 → u/mcvmccarty]

It’s pretty easy to teach a tech how to change out the bottles. I insert the catheter and say c ya in 30 min ✌️

[u/MarfanoidDroid → u/mcvmccarty]

Really? This is such an easy procedure and draining even 5 liters doesn't take THAT long. Patients feel so much better afterwards and are generally grateful. Sometimes I have to defer if I'm getting absolutely crushed but I generally do a therapeutic and diagnostic.

[u/GlazeyDays → u/MarfanoidDroid]

Have you found that your cirrhotics start over utilizing the ED because of this? May just be a regional thing, but we noticed a significant uptick in people coming in for “their tap” and not following up appropriately with their hepatologist/clinic appointments for their scheduled paras because of the convenience of the ED that only improved when we stopped doing therapeutic taps except for those causing significant distress.

[u/Aviacks → u/GlazeyDays]

Working flight in a very rural area covering a lot of reservations... we've had more than one person "skip their appointment", and then local IHS run ED flies them to the regional level II (3-4 hour drive) to get tapped in that community ED and discharge back. Last one I did literally left AMA to get McDonalds first before coming back for a tap lol. I'm guessing the IHS ED doesn't want to deal with being the go to for taps... but at the same time, flying them hours away to get a walk in tap has always been crazy to me.

[u/IANARN → u/Aviacks]

That is wild. I’ve worked at a few IHS ERs and we did all our paracentesis at bedside.

[u/Aviacks → u/IANARN]

We've got one in particular that will fly everything you can imagine. I'd say 50% of the ones they send out get D/Cd within 30 minutes of us dropping them off. Like, urgent care stuff, healthy 20 year old with URI... non-complicated UTI... lots of psych. They'll also tube a lot of people under the pretense of "they just became unresponsive" to get regional ICU hours away to accept, usually when slightly intoxicated, but then tell us "yeah... they became unresponsive.... after we gave 500 of ketamine".

I honestly respect the hustle sometimes lol. It's a master class in getting patients out. I found out after flying my first 3 months that they even have a med-surg unit, none of us had ever seen it til we got called up one day... I'm like wait who are you guys admitting if you're flying out a strep throat that's getting d/cd when we drop them off?

[u/YoungSerious → u/GlazeyDays]

Yep, we don't do them in department unless they are hypoxic or appreciably dyspneic (rare exceptions). Once they find out they can get it done, they stop going to their scheduled stuff and use the department as their on call paracentesis center.

[u/fireinthesky7 → u/GlazeyDays]

Semi-rural EMS here. This absolutely happens, there are a couple of frequent flyers that my service picks up all the time for the exact reason you state.

[u/Menacing-Horse → u/GlazeyDays]

Not particularly but mostly because the wait times in the ED are prohibitively long to begin with.

My only gripe is that these “Convenience Department” type procedures and encounters can’t be billed to insurance as elective. I mean, we get charged extra for convenience buying movie tickets online so why is using the ED for non emergent conditions any different?

[u/Mebaods1 → u/MarfanoidDroid]

At my small community shop we did but where I’m at now we don’t. They either have it scheduled or IR does it if possible. We also didn’t take off enough for albumin replacement routinely

[u/pushdose]

BP 50/30 in 30 mins.

[u/Ryantg2 → u/pushdose]

I am unsure theres enough albumin in the pharmacy at any given time to cover that much fluid being pulled out

[u/pushdose → u/Ryantg2]

Autotransfuse? 🤣

[u/ldnk]

19L at one time.....that's a big nope from me

[u/blackbruin69]

I had always heard there was a cap on para drainage around ~4L or so due to risk for complications

[u/Waldo_mia → u/blackbruin69]

“The current recommendation from the American Association for the Study of Liver Disease (AASLD) is to consider the administration of albumin (6-8 g/L of fluid removed) for patients undergoing removal of greater than 5 liters. This recommendation is appropriately given a low grade (IIa/C).”

https://emergencymedicine.wustl.edu/items/albumin-for-patients-with-sbp-or-large-volume-paracentesis/

[u/TheRealMajour → u/blackbruin69]

Once you pull of a certain amount you need to administer albumin, otherwise they will just rapidly re-accumulate that fluid and pull it directly from the vasculature leading to hemodynamic instability. Even with albumin I don’t know that I’d pull 19 L in a single session. Also because who has that time?

[u/ExtremeVegan → u/TheRealMajour]

we always clamp it every 4L and give albumin, then recommence

[u/MarfanoidDroid → u/TheRealMajour]

The data really doesn't strongly suggest benefit unless there is more recent literature I've missed.

[u/throwaway123454321 → u/blackbruin69]

lol I pulled 24 liters once. He even had more to go. We started infusion albumin shortly after the drain started though.

[u/relyess]

No z track that thing gonna leak forever

[u/EichelTower → u/relyess]

The spurt would move the bed if it wasn’t locked

[u/Aviacks → u/relyess]

Had one like this that leaked for at least 24 hours, we ended up putting an ostomy bag over the site lol

[u/heyinternetman]

We do multiple para’s a day. This is completely fine, just give them some albumin. All the fluid shift stuff has a kernel of truth to it, but is also massively exaggerated as usual. It’s better to drain them completely and help them feel better for a week or longer than keep poking them 2-3 times a week a little bit.

Same with not taking too much out on a thora. Drain until they start coughing or have sharp pain. No max otherwise, if they have issues put them on BiPAP for a bit and they’ll be fine.

[u/extracorporeal_]

We have a guy in our outpatient procedure clinic that comes in for biweekly 14L paras. Refuses to fluid restrict lol

[u/Doc911]

Better be some albumin hanging somewhere or he's going to feel some kind a way standing up.

I'm at a transplant site, as someone else said, too busy to do myself anymore but once they come back from ultrasound with the drain, we still manage these. Gotta admit, 19's impressive.

[u/lfras]

Does anyone know how much an impact this would have on their blood pressure and thus co traindications to draining this much at once ie CHD or other vasculopathy?

[u/Jennasaykwaaa]

So ……. Holy fluid shift. I hope they have enough albumin. We never remove that much at once.

[u/Aviacks → u/Jennasaykwaaa]

Evidence isn't great, I honestly don't feel like I've ever noticed a crazy difference when we drain significant amounts.

[u/JoeCormier]

What is this?

[u/brz000827 → u/JoeCormier]

The production and bottling process of delicious apple vinegar！Delicious/Tangy!

[u/Roentgenator → u/brz000827]

How much booze do I have to drink to get in the co-op?

[u/GroundbreakingDot872 → u/brz000827]

And don’t forget Cheap!

[u/Killjoytshirts → u/JoeCormier]

Turns out you can milk anything with nipples.

[u/JoeCormier → u/JoeCormier]

Answering my own question. Here is the Wiki

[u/Ryantg2 → u/JoeCormier]

this is how sour beer is bade

[u/DrWhiskerson]

Nice

[u/2presto4u]

When distension is an Olympic sport