Cirrhotic Ascites and Edema 53
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Vasopressin/Nitroglycerine Paste Therapy:
-Vasopressin (Pitressin) 20 U IV over 20-30 minutes, then 0.2-0.3 U/min
[100 U in 250 mL of D5W (0.4 U/mL)] for 30 min, followed by increases
of 0.2 U/min until bleeding stops or max of 0.9 U/min. If bleeding stops,
taper over 24-48h AND
-Nitroglycerine paste 1 inch q6h OR nitroglycerin IV at 10-30 mcg/min
continuous infusion (50 mg in 250 mL of D5W).
10. Extras: Portable CXR, upright abdomen, ECG. Surgery and GI consults.
Upper GI Bleeds: Esophagogastroduodenoscopy with coagulation or
sclerotherapy; Linton-Nachlas tube for tamponade of esophageal varices.
Lower GI Bleeds: Sigmoidoscopy/colonoscopy (after a GoLytely purge 6-8 L
over 4-6h), technetium 99m RBC scan, angiography with embolization.
11. Labs: Repeat hematocrit q2h; CBC with platelets q12-24h. Repeat INR in 6
hours. SMA 7&12, ALT, AST, alkaline phosphatase, INR/PTT, type and cross for
3-6 U PRBC and 2-4 U FFP.
Cirrhotic Ascites and Edema
1. Admit to:
2. Diagnosis: Cirrhotic ascites and edema
3. Condition:
4. Vital signs: Vitals q4-6 hours. Call physician if BP >160/90, <90/60; P >120,
<50; T >38.5
C; urine output < 25 cc/hr for 4h.
5. Activity: Bed rest with legs elevated.
6. Nursing: Inputs and outputs, daily weights, measure abdominal girth qd,
guaiac all stools.
7. Diet: 2500 calories, 100 gm protein; 500 mg sodium restriction; fluid restric-
tion to 1-1.5 L/d (if hyponatremia, Na <130).
8. IV Fluids: Heparin lock with flush q shift.
9. Special Medications:
-Diurese to reduce weight by 0.5-1 kg/d (if edema) or 0.25 kg/d (if no edema).
-Spironolactone (Aldactone) 25-50 mg PO qid or 200 mg PO qAM, increase
by 100 mg/d to max of 400 mg/d.
-Furosemide (Lasix)(refractory ascites) 40-120 mg PO or IV qd-bid. Add KCL
20-40 mEq PO qAM if renal function is normal OR
-Torsemide (Demadex) 20-40 mg PO/IV qd-bid.
-Metolazone (Zaroxolyn) 5-10 mg PO qd (max 20 mg/d).
-Ranitidine (Zantac) 150 mg PO bid.
-Vitamin K 10 mg SQ qd for 3d.
-Folic acid 1 mg PO qd.
-Thiamine 100 mg PO qd.
-Multivitamin PO qd.
Paracentesis: Remove up to 5 L of ascites if peripheral edema, tense
ascites, or decreased diaphragmatic excursion. If large volume para-
centesis without peripheral edema or with renal insuffiencey, give salt-poor
albumin, 12.5 gm for each 2 liters of fluid removed (50 mL of 25%
