Journal of Pediatric Gastroenterology and Nutrition
33:245–249 © September 2001 Lippincott Williams & Wilkins, Inc., Philadelphia
Large-Volume Paracentesis in the Management of Ascites
in Children
*Robert E. Kramer, *†Ronald J. Sokol, *Baruch Yerushalmi, *Edwin Liu, †Todd MacKenzie,
*Edward J. Hoffenberg, and *Michael R. Narkewicz
*Pediatric Liver Center and Liver Transplantation Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition,
Department of Pediatrics, and the †Pediatric General Clinical Research Center, The Children’s Hospital and University of
Colorado Health Sciences Center, Denver, Colorado, U.S.A.
ABSTRACT
Background: Large-volume paracentesis has been evaluated
for both therapeutic and diagnostic purposes in the manage-
ment of ascites in cirrhotic adults. There are no published data
relating to the safety, efficacy, or methods of this procedure in
children. The objective of this study was to characterize the
authors’ initial experience with large-volume paracentesis (>
50 ml/kg of ascites) for removal of tense abdominal ascites in
the pediatric population.
Methods: Retrospective chart review was performed of 21
large-volume paracentesis sessions in seven children (ages 6
months–18 years) with tense ascites that did not respond to
other measures.
Results: Mean volume removed was 3,129 ± 2,966 ml (mean
± standard deviation) or 118 ± 56 ml/kg over 2.9 ± 3.7 hours by
a 16-gauge intravascular catheter in 6 sessions, by an 18-gauge
Ascites is a frequently encountered complication of
cirrhosis in both children and adults. The management of
ascites includes salt and fluid restriction, treatment with
diuretics, surgical shunt placements, transjugular intra-
hepatic portosystemic shunting, and liver transplantation.
In adults, large-volume paracentesis (LVP) is an addi-
tional safe and effective technique for the management
of tense, unresponsive abdominal ascites (1). In fact, pul-
monary function testing shows marked improvement af-
ter LVP in patients with pulmonary compromise result-
ing from tense ascites (2,3).
The first report of the use of paracentesis in children
was by Denzer in 1920 (4), who advocated its use for
Received September 11, 2000; revised March 22, 2001 and May 3,
2001; accepted May 17, 2001.
Presented at the 2000 World Congress of Pediatric Gastroenterology,
Hepatology and Nutrition, August 5–9, 2000, Boston, MA, and pub-
lished in abstract form (JPGN 2000;31(2):S113).
Address correspondence and reprint requests to Dr. Ronald J. Sokol,
The Children’s Hospital, Box B-290, 1056 East 19th Avenue, Denver,
CO 80218, U.S.A. (e-mail: sokol.ronald@tchden.org).
245
intravascular catheter in three sessions, and by a 15-gauge fe-
nestrated, stainless-steel paracentesis needle in 12 sessions.
Large-volume paracenteses performed with the paracentesis
needle had significantly shorter duration of drainage and faster
flow rates than those performed with the intravascular catheter.
The only complication encountered was decreased urine output
in one session.
Conclusions: Large-volume paracentesis is a safe and effective
therapeutic method for managing tense abdominal ascites in
children. The use of the paracentesis needle significantly im-
proved the speed and efficiency of large-volume paracentesis
compared with the intravascular catheter. JPGN 33:245–249,
2001. Key Words: Caldwell paracentesis needle—Large-
volume paracentesis—Ascites—Pediatric. © 2001 Lippincott
Williams & Wilkins, Inc.
diagnosis in pediatric peritonitis. Subsequently, paracen-
tesis has been advocated for the diagnosis of urinary (5),
cardiac (6), traumatic (7), and chylous ascites (8) in in-
fants and children. However, the use of LVP as a treat-
ment for ascites in children has not been reported. We
have used this technique for the past 3 years in children
with tense ascites poorly responsive to other treatments.
The objectives of this initial report were to review the
safety and efficacy of LVP in the management of ascites
and to compare the speed and efficacy of LVP using two
types of catheters.
MATERIALS AND METHODS
Patients
This study was a retrospective review of all LVPs performed
at The Children’s Hospital by the Department of Pediatric Gas-
troenterology, Hepatology and Nutrition between January 1,
1997 and June 16, 2000. For the purpose of this study, LVP was
defined as removal of 50 ml or more of ascitic fluid per kilo-
246 R. E. KRAMER ET AL.
gram of dry body weight. There were a total of 21 LVP sessions
performed in seven children that satisfied the above criteria. All
seven patients had tense abdominal ascites with either abdomi-
nal discomfort or respiratory compromise. All seven had been
treated with combination diuretics ranging from 0.5 to 2.0
mg/kg per day for furosemide and 0.3 to 2.25 mg/kg per day for
spironolactone. Six of the seven were treated with a standard
sodium restricted diet limited to 1 to 2 mEq/kg per day for the
infants and children and 1 to 2 g/day in the adolescents.
Large-Volume Paracentesis Technique
Informed consent was obtained from patients or families
before each LVP procedure. Patients fasted for at least 2 to 4
hours while receiving maintenance intravenous fluids before
the procedure. The LVP procedure was performed with the
patient in the supine position and usually under conscious se-
dation with intravenous midazolam, meperidine, or both. Base-
line complete blood count (n ⳱ 19) and prothrombin time (n ⳱
12) were obtained before the procedure. Blood products were
administered on an individual basis; platelets were typically
infused if platelet count was less than 50,000, and fresh frozen
plasma was given if prothrombin time was prolonged more
than 5 seconds above normal. All patients underwent abdomi-
nal ultrasonography before the initial LVP to locate a safe site
for paracentesis. Local analgesia was achieved by administra-
tion of topical 2.5% lidocaine and 2.5% prilocaine cream
(EMLA cream; Astra Pharmaceuticals, Wayne, PA) 30 to 60
minutes before the procedure or by infiltrating the site with 1%
lidocaine immediately before catheter insertion. Either a 16-
gauge (n ⳱ 6) or 18-gauge (n ⳱ 3) Teflon intravenous catheter
[IC] (Quik-Cath; Baxter Healthcare Corporation, Deerfield, IL)
or a 15-gauge (n ⳱ 12) paracentesis needle [PN], (Caldwell
needle; Ballard Medical Products, Draper, UT) was used, de-
pending on physician preference. The PN consists of an 8.25-
cm stainless steel canula with a blunt tip, two fenestrations
along each side, a removable beveled stylet that sits inside the
canula, and a flared lip at the top, allowing it to be connected
to a standard three-way stopcock device. Insertion was per-
formed using the “Z technique” of repositioning the needle
before entry into the peritoneal cavity whenever possible to
minimize leakage after removal of the catheter. After return of
ascitic fluid, the stylet was removed and the catheter left in
place and attached to a three-way stopcock. Samples were col-
lected for laboratory testing, and then the stopcock was con-
nected to a sterile collection system for drainage by gravity. For
the IC technique, the stopcock assembly was covered with a
paper cup and taped to the abdomen during drainage to prevent
dislodging by the child. This was not usually necessary for
LVPs performed using the PN because of the much shorter
collection time. Vital signs, oxygen saturation, and urine output
were recorded every 15 minutes during the procedure. Infu-
sions of intravenous albumin were also administered on an
individual basis to provide hemodynamic stability and replace-
ment for removed ascitic protein (albumin); 0.5 to 1.0 g of 5%
albumin per kilogram of dry weight were infused over 1 to 2
hours beginning at the time of catheter insertion. The choice of
5% over 25% albumin was based on efficacy of intravascular
volume expansion. The paracentesis catheters were removed
when drainage stopped or slowed considerably, and a pressure
dressing was applied.
J Pediatr Gastroenterol Nutr, Vol. 33, No. 3, September 2001
Data Collection
Data obtained from patient records for this study included
the volume of ascites removed, the duration of drainage, the use
of ultrasound guidance, needle type, complications, use of in-
travenous albumin, ascitic fluid analysis results, and coagula-
tion status of the patients. Ascitic fluid volume removed was
expressed as total volume per kilogram dry body weight, vol-
ume per hour, and volume per kilogram of dry body weight per
hour.
Statistical Analysis
Data were analyzed using standard Sigmastat statistical soft-
ware (SPSS Inc., San Rafael, CA) and are presented as mean ±
standard deviation. Comparisons between the PN, 16-gauge IC,
and 18-gauge IC were performed using one-way analysis of
variance, with Kruskal-Wallis analysis of variance where ap-
propriate, and post hoc Tukey two-sample t test for pairwise
comparison. Statistical comparison of the PN versus the com-
bined IC (16 gauge plus 18 gauge) was also performed using
the Student’s t test. Statistical significance was considered a P
value < 0.05.
RESULTS
Seven patients ages 7 months to 19 years (mean age,
7.8 years), underwent a total of 21 LVP procedures at our
institution during the 3-year study period (Table 1). The
first patient underwent three LVPs over a 7-month period
for ascites caused by chronic liver allograft rejection and
cirrhosis. The second patient underwent one therapeutic
LVP for ascites caused by hepatic failure that developed
as a complication of Epstein-Barr virus-associated he-
mophagocytic syndrome. The third patient underwent
three LVP procedures over a 2-month period for ascites
secondary to congenital hepatic fibrosis, after undergo-
ing a renal transplant. His recurrent ascites resolved after
placement of a spleno-renal shunt. The fourth patient
underwent eight LVPs over a 2-month period for chylous
ascites occurring after surgery for a retroperitoneal Ka-
posiform hemangioendothelioma. A peritoneovenous
shunt was eventually placed, however, the postoperative
course was complicated by cardiac and respiratory fail-
ure and the shunt was removed subsequently. She is
stable on chemotherapy. The fifth patient underwent
three LVPs over a 12-month period for ascites caused by
Budd-Chiari syndrome. Ascites resolved after he re-
ceived an orthotopic liver transplant. The sixth patient
underwent one LVP for ascites that developed secondary
to veno-occlusive disease after stem cell rescue for treat-
ment of medulloblastoma. After initial LVP, veno-
occlusive disease improved and the ascites were con-
trolled with diuretic therapy alone. The seventh patient
underwent two LVPs for ascites that developed after or-
thotopic liver transplantation for carbamyl phosphate
synthetase deficiency. She was subsequently found to
have a necrotic edge of the reduced-size liver allograft;
 LARGE-VOLUME PARACENTESIS FOR ASCITES IN CHILDREN 247

TABLE 1. Large-volume paracentesis data

U/S Total
Patient Wt Plt PT Guided Catheter Vol Time Ascitic ANC Ascitic RBC Alb
number (kg) LVP# (×103) (s) (yes/no) type (mL) ml/kg (hr) (cells/mm3) (cells/mm3) (gm/kg) Complications

1 79.4 1 125 17.4 yes 16 g IC 6300 79 13 4 489 0.6 Decreased UOP

18 yo male 2 N/D 17.7 yes 18 g IC 7350 97 4 1501 195 0.7 None
Chronic rejection 3 63 18.6 yes 18 g IC 6900 93 5 674 235 1.0 None
s/p OLT
2 14.0 1 29 22 no 15 g PN 1150 82 0.17 1 2100 1.6 None
2 yo male
Hepatic failure due to
EBV associated HPS
3 23.7 1 79 13.8 yes 16 g IC 2010 84 8.25 51 4 0.9 None
10 yo male 2 124 N/D yes 16 g IC 3150 133 4.5 3 770 1.0 None
CHF/PKD 3 73 N/D yes 15 g PN 3475 146 4 1 1045 0.5 None
4 6.1 1 124 N/D no 15 g PN 500 82 0.25 3 340000 0.5 None
7 mo female 2 50 14.3 no 18 g IC 650 106 0.25 21 170000 0.5 None
Hemangio- 3 N/D N/D no 15 g PN 800 130 0.25 N/D N/D 0.5 None
endothelioma 4 39 N/D no 15 g PN 800 130 0.25 65 100000 0.5 None
5 69 N/D no 15 g PN 800 130 0.25 0 49000 0.5 None
6 75 N/D no 15 g PN 1360 220 0.5 8 10400 0.8 None
7 9 N/D no 15 g PN 1400 227 0.25 152 270000 0.8 None
8 194 15.0 no 15 g PN 1625 263 0.25 14 140000 0.8 None
5 97.0 1 495 33.1 yes 16 g IC 7950 82 6 224 220000 0.7 None
17 yo male 2 652 24.3 no 16 g IC 9150 94 9 3 210000 0.2 None
Budd-Chiari 3 1020 18.6 no 16 g IC 7225 74 4.75 473 1170000 None None
6 20.0 1 27 14.3 yes 15 g PN 2000 100 0.33 12 35000 0.5 None
6 yo male
VOD s/p stem cell rescue
7 8.3 1 133 18.6 yes 15 g PN 415 50 0.25 104 1130 0.6 None
13 mo female 2 277 N/D yes 15 g PN 700 84 0.12 5 686 0.6 None
CPS deficiency s/p OLT

Wt, weight; LVP, large volume paracentesis; OLT, orthotopic liver transplant; EBV, Epstein Barr virus; HPS, hemophagocytic syndrome; CHF, congenital hepatic
fibrosis; PKD, polycystic kidney disease; VOD, venoocclusive disease; CPS, carbamyl phosphate synthetase; s/p, status post; mo, month old; yo, year old; Plt, platelet
count; PT, prothrombin time; IC, intravascular catheter; PN, paracentesis needle; U/S, ultrasound; Total Vol, ascitic volume removed; ANC, absolute neutrophil count;
RBC, ascitic red blood cell count; Alb, intravenous albumin administered; UOP, urine output; N/D, not done.

ascites resolved after resection of this necrotic liver tis-

sue. Aggregate data for all patients is shown in Table 2. TABLE 2. Aggregate patient data
In three LVP sessions (14%), the absolute neutrophil Mean ± SD
count of the ascitic fluid was found to be more than
250/mm3, which was considered diagnostic for sponta- Mean volume removed (mL) per LVP 3,129 ± 2,965
Mean ml/kg removed per LVP 118 ± 56
neous bacterial peritonitis despite the fact that all cul- Mean duration of drainage (h) per LVP 2.9 ± 3.7
tures remained negative. All three were treated empiri- Percent of ultrasound guided LVPs 48%
cally with intravenous third-generation cephalosporin Percent of LVPs with ascitic neutrophil count 14%
therapy. No bacteremia or sepsis was identified as a com- >250/mm3
Percent treated for SBP after LVP 14%
plication of LVP. Albumin concentration of ascitic fluid Percent infused with IV albumin after LVP 95%
ranged from 1.0 to 3.0 g/dL (mean, 1.79 ± 0.71 g/dL) and Mean dose of albumin given (gm/kg) after LVP 0.6 ± 0.3
protein concentration ranged from 743 to 4600 mg/dL PT normal (% of patients) 8%
(mean, 2,225 ± 1,318 mg/dL). Ascitic amylase levels PT prolonged 1–5 seconds (% of patients) 67%
ranged from 4 to 220 IU/L (mean, 37.8 ± 57.2 IU/L), and PT prolonged >5 seconds (% of patients) 25%
Percent of patients infused with FFP before LVP 25%
triglyceride levels ranged from 10 to 972 mg/dL (mean, Complications per LVP
215.8 ± 255.8 mg/dL). Results of ascitic cell counts are Hypotension None
given in Table 1. Decreased urine output 1 LVP
Comparison of catheters used for LVPs by one-way Hemorrhage None
Ascitic leakage None
analysis of variance (Table 3) showed that there were
significant differences between the three groups in flow PT, prothrombin time; FFP, fresh frozen plasma; LVP, large volume
rate (milliliters per hour; P ⳱ 0.001), weight-adjusted paracentesis; SBP, spontaneous bacterial peritonitis.

J Pediatr Gastroenterol Nutr, Vol. 33, No. 3, September 2001

248
TABLE 3. Comparison of 15-gauge Caldwell paracentesis needle versus 16- and
18-gauge intravascular catheter in LVP
No. of LVPs
Volume removed (mL/kg)
Duration of drainage (hr)
Velocity of drainage (mL/hr)
Weight adjusted velocity (mL ⭈ kg−1 ⭈ hr−1)
* Statistically significant.
PN, paracentesis needle; IC, intravascular catheter; LVP, large volume paracentesis; g, gauge;
ANOVA, analysis of variance.
Values expressed as mean ± standard deviation. Data compared by one-way ANOVA, significance
considered as P < 0.05.
flow rate (milliliters per kilogram per hour; P < 0.001),
and duration of drainage (hours; P ⳱ 0.004). Drainage
volume per kilogram of body weight (milliliters per kilo-
gram) was also greater with the PN than with either of
the IC catheters, however, results did not achieve statis-
tical significance (P ⳱ 0.2). Subsequent pairwise analy-
sis of the groups showed that for milliliters per hour,
milliliters per kilogram per hour, and hours there were
significant differences between the PN and 16-gauge
groups (P ⳱ 0.004, P < 0.001, and P < 0.001) but not
between the PN and the 18-gauge groups (P ⳱ 0.17, P
⳱ 0.08, and P ⳱ 0.13), although this was expected
because of the small number of LVPs in the 18-gauge
group (n ⳱ 3). Therefore, a repeat comparison was per-
formed using the Student’s t test after combining the
16-gauge and 18-gauge LVPs into a single IC group. It
showed the PN to have significantly faster flow rate (mil-
liliters per hour; P ⳱ 0.001), faster weight-adjusted flow
rate (milliliters per kilogram per hour; P < 0.001), and
shorter duration of drainage (hours; P < 0.001) than the
IC group. Both triglyceride and protein concentrations of
the ascitic fluid were not significantly different among
the catheter groups (P ⳱ 0.16 and P ⳱ 0.45, respec-
tively) and therefore were not believed to account for the
differences observed in flow rates. All procedures were
well tolerated, with the only complication being a mild
decrease in urinary output in one patient, who responded
well to volume expansion. There was no evidence of
significant hemorrhage or leakage complicating any of
the procedures.
DISCUSSION
Although LVP is frequently used in adults for the
management of recurrent ascites resistant to medical
therapy, its role in pediatric patients has not been de-
fined. Our experience demonstrates that a large volume
of ascitic fluid can be removed quickly, even from small
infants, with minimal complications. The decreased
urine output that was observed in one of our patients
during LVP drainage was mild and responded to addi-
tional administration of intravenous albumin. Gines et al.
J Pediatr Gastroenterol Nutr, Vol. 33, No. 3, September 2001
R. E. KRAMER ET AL.
15 g PN 16 g IC 18 g IC p Value
12 6 3
137 ± 61 90 ± 22 99 ± 7 0.2
0.6 ± 3.1 7.6 ± 3.2 3.1 ± 2.5 0.001*
3930 ± 2201 882 ± 494 1939 ± 616 0.004*
496 ± 325 14 ± 8 155 ± 232 <0.001*
(9) have performed controlled trials in adults comparing
LVP with and without the use of albumin and found that
intravenous albumin replacement reduces renal and elec-
trolyte complications. Although alternative, less expen-
sive volume expanders, such as Dextran 70, have been
found to be equally efficacious as albumin in preventing
these complications after LVP, use of Dextran 70 after
LVP still resulted in increased renin and aldosterone ac-
tivity (10). Use of alternative volume expanders in chil-
dren has not been studied. Therefore, we chose to use
albumin for both volume expansion and to avoid impos-
ing any additional nutritional stress caused by removal of
ascitic protein. Although nitrogen balance after serial
LVP was not studied, in our experience, removal of as-
cites after LVP resulted in improved appetite and oral
intake. We recognize that repeated removal of a large
volume of ascites has the potential to cause protein
depletion, and therefore recommend adequate oral pro-
tein intake and albumin infusions to prevent further pro-
tein losses. We initially chose to use 5% albumin to
provide volume and albumin replacement concurrently.
Inasmuch as we did not observe significant hemody-
namic instability after LVP, we are now administering
25% albumin, as is used with LVP in adults (1).
Using the Z technique whenever possible, we did not
observe any episodes of leakage from the LVP site, de-
spite repeated procedures in the same area. The Z tech-
nique was more difficult to perform in the infants be-
cause of the relatively thin abdominal wall. Intraperito-
neal hemorrhage, one of the potential complications, was
not encountered in our series, despite the fact that co-
agulopathy and thrombocytopenia were present in a
number of our patients. Based on ultrasound guidance,
many of the LVPs were performed in either the right or
left lower quadrants, where a greater potential risk of
bleeding exists because of the vasculature of the rectus
abdominus muscles. We chose to infuse fresh-frozen
plasma before LVP if the PT was more than 5 seconds
above the upper limit of normal for age, and platelets
were given to maintain a platelet count of at least
50,000/mm3 before and for 1 to 2 days after the proce-
dure. In adults, however, recent studies show that the
severity of thrombocytopenia or coagulopathy did not
 LARGE-VOLUME PARACENTESIS FOR ASCITES IN CHILDREN
increase the risk of hemorrhage in LVP (11). Thus, the
correction of coagulopathy in children undergoing LVP
may not be required. The suspected mechanism of intra-
peritoneal hemorrhage after LVP is a rapid increase in
the pressure gradient across the wall of mesenteric vari-
ces resulting from the sudden drop in intraperitoneal
pressure with drainage, leading to rupture of the vessels.
Mortality from hemorrhage of mesenteric varices is re-
ported to be as high as 70% in adults, occurring any-
where between 3 hours and 4 days after LVP (12). In our
patient with hemangioendothelioma and our patient with
Budd-Chiari syndrome, the high number of red blood
cells found in the ascitic fluid was believed to be caused
by their primary illnesses. Neither had a significant drop
in hematocrit after LVP.
The necessity of a preprocedure abdominal ultrasound
has not been established. Although not all of our LVPs
were under ultrasound guidance, at least one ultrasound
examination was performed to determine an appropriate
site before the first LVP was performed on all patients.
For patients with a relatively short interval between
LVPs, ultrasonography was not always repeated.
The optimal catheter system to be used for LVP in
children had not been addressed before this report. Suc-
cess using a peritoneal dialysis catheter system (13), in
addition to the IC, has been reported in adults. Newer
paracentesis needles have been developed to hasten flow
rates of the drainage of ascites in a safe manner. In a
study of adults with ascites comparing the PN with the
IC, both connected to negative pressure, the PN had sig-
nificantly faster flow rates, decreased need for subse-
quent paracenteses, and fewer premature terminations re-
sulting from poor fluid return (14). Our experience with
the PN draining to gravity was similar in that rate and
duration of drainage were significantly improved com-
pared with IC, without compromising safety. The fenes-
trations and rigidity of the PN allow better flow and
therefore required less repositioning as drainage pro-
gressed. Although the faster rate of drainage with the PN
may raise concerns about hemodynamic instability, this
was not observed. Advantages of the shorter drainage
time may be a reduction in the risk of infection and the
ability of the physician to remain at the bedside through-
out the procedure. The 3.75-inch (9.53-cm) length of the
PC could not be inserted completely into the abdomen of
the smaller patients, although it still worked well with
only partial insertion as long as all of the fenestrated
holes were below the surface of the skin. Although this
was a retrospective study with a small number of patients
that carries the risk of physician bias in catheter selec-
249
tion, the dramatic difference in flow rates observed be-
tween the PN and the IC argues against undue influence
on the results.
In summary, LVP was both safe and effective in our
initial experience in pediatric patients. Use of a fenes-
trated, stainless-steel paracentesis needle offered signifi-
cant advantages over intravascular catheters in increas-
ing the flow rate of drainage and shortening the duration
of the procedure, as it does in draining ascites in adults.
Using our technique, the only complication encountered
was decreased urine output, which was readily amenable
to volume expansion. Although prospective studies in
adults with ascites have addressed the issues of volume
expansion, rapidity of drainage, coagulopathy correction,
and types of paracentesis needles to be used in LVP,
these issues, as well as nutritional status of children un-
dergoing repeated LVP, require further study in the pe-
diatric population.
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