Long-term intraperitoneal catheters: A novel ambulatory care intervention for the management of refractory cirrhotic ascites during COVID-19

Background and Aim: The coronavirus disease 2019 (COVID-19) pandemic has created challenges in how health care systems provide care for patients with refractory cirrhotic ascites We aimed to investigate the safety and efficacy of a novel ambulatory care program developed with Hospital in the Home (HITH) to allow frequent low-volume ascitic drainage through a long-term, tunneled, intraperitoneal catheter (IPC;Rocket Medical) in patients with advanced cirrhosis Methods: We conducted a prospective cohort study at a Victorian tertiary health care service from April to July 2020 Adult patients with refractory cirrhotic ascites requiring large-volume abdominal paracentesis twice in the past 8 weeks were recruited We excluded patients otherwise eligible for transjugular intrahepatic portosystemic shunt (TIPS) insertion or liver transplantation and those with Child-Pugh C disease, prior spontaneous bacterial peritonitis, active infection, loculated ascites, or hepatic hydrothorax All IPCs were inserted by an interventional radiologist and managed for 12 weeks by HITH in lieu of recurrent hospital admission for large-volume paracentesis The drainage schedule was individualized, with 1-6 L drained by HITH nurses over 1-3 sessions per week, without human albumin infusions All patients received antibiotic prophylaxis (norfloxacin 400 mg daily or trimethoprim-sulfamethoxazole 160-800 mg daily) The primary endpoint was safety (death related to IPC, rates of bleeding, peritonitis, and cellulitis), with secondary endpoints including symptom burden, IPC attrition rates, and quality of life (EuroQol 5 dimensions) Results: Five patients (median age, 60 years;IQR, 53-74;four male) underwent insertion of an IPC All had Child-Pugh B disease, with a median Model for End-Stage Liver Disease score of 11 (IQR, 9-13) The etiology of liver disease was alcohol (n = 4) and hepatitis C (n = 1) All patients were ineligible for TIPS due to prior hepatic encephalopathy and ineligible for liver transplantation due to active alcohol use (n = 3), advanced age (n = 1), and underlying malignancy (n = 1) There were no deaths during the follow-up period and only one adverse event (cellulitis) IPC attrition rate over the 12-week program was 100% The IPC was removed in one patient due to resolution of ascites at Week 11 and in a second patient due to non-compliance at Week 13 At 30 days after IPC insertion, the median self-reported health score on a vertical visual analog scale increased from a median of 50 (IQR, 50-70) to 78 (IQR, 50-85), attributable to a reduction in symptom burden Conclusion: Long-term tunneled IPCs for the management of refractory cirrhotic ascites were safe The IPC was associated with improved symptom control and patient perceptions of health, compared with baseline The study is ongoing, and a larger sample size will allow further exploration of the safety and cost-effectiveness of this novel intervention in a vulnerable population during and after the COVID-19 pandemic