Proposed Clinical Guidelines for Abdominal and Pleural Paracentesis with Emphasis on Large-Volume Paracentesis

Large-volume paracentesis (LVP) of the peritoneal and pleural cavities is a common therapeutic and diagnostic intervention in patients with liver cirrhosis or advanced heart failure, which are often complicated by ascites or pleural effusion. Although generally considered low-risk, the potential complications of LVP include intrapleural or abdominal hemorrhage or, more commonly, intraabdominal wall hemorrhage, organ puncture, and infection. Performing paracentesis in patients with coagulopathy or bleeding disorders, whether due to underlying disease or resulting from anticoagulant therapy, presents a major clinical dilemma. The safety thresholds for conducting the procedure in such patients vary, and the strategies for mitigating the bleeding risk remain debated, with no consensus reached across different professional societies. Based on our institutional experience and the current international literature, we herein present comprehensive recommendations for the safe and effective execution of LVP, based on evidence synthesis and expert consensus. This review may serve as a practical guide for clinicians performing LVP in high-risk patients.