Palliative long-term abdominal drains in refractory ascites due to end-stage liver disease: A case series.

BACKGROUND: Ascites, the commonest complication of cirrhosis, leads to frequent hospitalisations. Refractory ascites confers a median survival of 6 months without liver transplantation. In many, the management remains palliative (large-volume paracentesis). Despite calls for improvement, palliative and end-of-life care is not yet integrated into end-stage liver disease. Long-term abdominal drains are a palliative strategy in malignant ascites, but not end-stage liver disease. CASE PRESENTATION: A retrospective, single centre, case series review was performed of patients undergoing long-term abdominal drain placement for refractory ascites secondary to end-stage liver disease at a large teaching hospital between August 2011 and March 2013. Case management: Patients with end-stage liver disease and refractory ascites, where liver transplantation was not an option, were considered for long-term abdominal drains. Seven patients underwent successful long-term abdominal drain insertion after multi-professional assessment. Case outcome: Following long-term abdominal drain insertion, mean hospital attendances reduced to 1 (0-4) from 9 (4-21), with none for ascites management. Median survival after long-term abdominal drain insertion was 29 days (8-219). The complication rate was low and none life threatening. CONCLUSION: Palliative and end-of-life care needs in end-stage liver disease remain under-addressed. Our data suggest that long-term abdominal drains may be a safe and effective palliative intervention in end-stage liver disease. Prospective randomised controlled trials comparing large-volume paracentesis versus long-term abdominal drains in refractory ascites secondary to end-stage liver disease are warranted.

A UK wide survey on attitudes to point of care ultrasound training amongst clinicians working on the Acute Medical Unit.

The use of point of care ultrasound (POCU) is increasing across a number of specialties, becoming mandatory within some specialist training programmes (for example respiratory and emergency medicine). Despite this, there are few data looking at the prevalence of use or the training clinicians have undertaken; this survey sought to address this. It shows that the majority of POCU undertaken on the Acute Medical Unit (AMU) is without formal accreditation, with significant arriers to training highlighted including a lack of supervision, time and equipment. For those who undertook POCU, it was shown to regularly speed up clinical decision making, while 76.3% respondents believed a lack of access to POCU out of hours may affect patient safety. The data provide support to the concept of developing AMU specific POCU accreditation, to ensure robust and safe use of this modality on the AMU.