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Background
New research cites the lack of evidence and utility in checking preprocedure labs for paracentesis in patients with cirrhosis. Many patients with decompensated cirrhosis are coagulopathic, with high International Normalized Ratio (INR) and low platelets, and, due to previously agreed-upon lab thresholds, they receive large infusions of blood products. The use of blood products in these patients is a waste of resources and puts the patient at risk of transfusion reactions, infection, and worsening volume status. A paracentesis, or abdominal tap, is a deceivingly simple, ubiquitously performed procedure on the wards and in the interventional suites. However, many are confused about the updated pre- and postprocedural management of patients with cirrhosis and ascites. This exhibit will review the need for preprocedure labs and whether preprocedural replacement of blood products is necessary. Furthermore, the exhibit will provide a review of the literature and societal recommendations for the use of albumin as a plasma expander in paracentesis so that providers understand how and why albumin works, for whom and when it is indicated, its limitations, and where further research is needed.

Educational Goals / Teaching Points
This educational exhibit will start with an overview of the basics of paracentesis that any performing provider should know, including indications, absolute and relative contraindications, methods, and preprocedure labs to order and review. Specifically, we will examine the previous guidelines for INR and platelet thresholds and whether these need to be checked at all prior to the procedure. After that, we will discuss the literature and societal recommendations for the use of plasma expanders in therapeutic paracentesis and delve into how and why albumin infusions work by reviewing concepts including osmosis, oncotic pressure, and the renin-angiotensin-aldosterone system (RAAS). Next, we will introduce post-paracentesis circulatory dysfunction (PPCD), an asymptomatic predictor of mortality in patients with ascites treated with large volume paracentesis, and how albumin plays a role in preventing PPCD. Dose recommendations and the efficacy of albumin infusions will be presented. The limitations of albumin will also be discussed, along with alternative plasma expanders and the data behind them. Finally, areas requiring more research will be touched on, including albumin infusion in patients with acute-on-chronic liver failure, in the pediatric population, and in those with malignancy-related ascites.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Concepts including osmosis, oncotic pressure, and RAAS will be reviewed.

Conclusion
Patients requiring paracentesis are critically ill, with life-threatening coagulopathy and severe hemodynamic derangements. Being mindful of their tenuous situation is important, but are we doing too much by trying to correct laboratory values more suited for the surgical setting? This educational exhibit will review the basics of paracentesis that every provider should know, specifically pre and postprocedure interventions that decrease the risk to the patient.