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Malignant Ovarian Ascites Can Be Draining

Monday August 25, 2003
Rachel Behrendt, RN, C, BA, nurse educator in the Oncology Department of Robert Wood Johnson University Hospital, New Brunswick, NJ, 
reviews the process for draining ascites.
Rachel Behrendt, RN, C, BA, nurse educator in the Oncology Department of Robert Wood Johnson University Hospital, New Brunswick, NJ, reviews the process for draining ascites.
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Susan* sits in the waiting room and she's tired. Tired of feeling sick, tired of being out of breath, tired of sitting in waiting rooms. Mostly, she's tired of having cancer. For the past two years, every couple of pages of her date book has listed an appointment for a test, a treatment, or a doctor's visit. Several long stretches of pages in the book have nothing at all written on them - they reflect time spent in the hospital. The worst of all is that she hasn't responded to the treatments, and the ovarian cancer has evolved to the point where she has ascites - she looks nine months' pregnant and is exhausted.
She wishes she could have a week where she feels good, where she has the energy to do life's mundane tasks like going to the grocery store, things she just can't manage anymore. She'd like a week without cancer. Barring that miracle, she'd take an hour where she could forget, "I am a person with cancer."
Ovarian cancer, one of the primary causes of malignant ascites, is a recurrent collection of fluid in the abdominal spaces characterized by the presence of cancer cells in the fluid. Ascites, usually a late development in the disease process, is sometimes caused by liver or gastrointestinal metastasis. This happens when the ovarian tumor or tumors impinge on the lymphatic system, and fluid becomes trapped in the peritoneal spaces. As the abdominal area expands, it presses upward on the diaphragm and causes severe breathing difficulties. Until recently, the only relief came with a paracentesis, which requires hospitalization.
Add Quality to Life
Rachel Behrendt, RN, C, BA, nurse educator in the Oncology Department of Robert Wood Johnson University Hospital, New Brunswick, NJ, frequently sees patients who have ascites. They are often in the prime of life and have families and responsibilities. Every moment of their lives is a precious gift, and they are loathe to spend an extra minute in the hospital. The repeated fluid build-ups and subsequent paracenteses rob them of these precious days at home. As an added problem, patients experience side effects to the paracentesis procedure itself. After repeated taps, the injection sites start to leak fluid, and the patient may need to use a dressing or even a pouch to control the drainage.
"Many of these patients spend so much energy getting to and from appointments, making arrangements for child care, and arranging their work schedules if they're still trying to work, it's exhausting," says Behrendt. "As caregivers, we need to be creative in finding ways to help these patients have their lives less disrupted and become more comfortable at home. It may mean giving up a little control, but it's worth it to the patient. The whole notion of palliative treatment is really coming into its own."
A recent addition to palliative treatment is the insertion of a Tenkoff catheter into the peritoneum to manage ascites at home. The patient is taught how to drain off fluid whenever she becomes uncomfortable or short of breath. For many women, this option has meant the difference between "life" and
"Sometimes the fluid builds up very quickly," says Behrendt. "We can see as much as 1,000cc per day collect [in the abdomen]. Because it's a palliative treatment, the patient can decide when she wants to do it [fluid tap], when she's feeling uncomfortable. She can do it [drain the fluid] and then just go about her business."
The presence of an indwelling peritoneal catheter means that the patient can fit the procedure into her day, instead of building the day around the procedure. In principle, it works like a faucet. It is a much simpler procedure and less disturbing to the patient's daily life than traditional paracentesis.
Simple Steps to Independence
Teaching a patient how to drain peritoneal fluid at home is not difficult, but the process must be done with strict observance of sterile procedure. The patient must do a three-minute hand wash and set up a strict sterile field before beginning to drain the fluid. Many of these patients are severely immuno-compromised - the number one complication is infection, and it can be a very serious development.
"In these patients, infection can be a life-ending event," says Behrendt, "and we have to teach them what to watch out for. They can have an acute, fulminating peritonitis before they even know they're sick."
By the time they are considered for at home management of ascites, most patients have been through the wringer. Body image concerns and the inconvenience of maintaining sterility during the procedure become secondary to the possibility of independence and leading a closer to normal life. Using the peritoneal catheter can mean immediate relief of symptoms in the comfort of one's own home.
The procedure isn't complicated once she understands sterile procedure. "She just removes the end cap of the catheter, attaches a sterile drainage bag and opens a couple of clamps," says Behrendt. The value of patient teaching cannot be overstated - the ability of the patient and family to manage the procedure themselves, their understanding of the need for absolute sterile technique, what to watch out for and report back to the healthcare provider, are critical.
The patient notes her weight before and after draining the fluid, reports the weight difference, the color and character of the fluid drained, and any odors. The fluid should be mostly clear and straw-colored, though there may be a brownish hue. Cloudiness or a greenish color are both causes for concern.
A Two-Way Street
Although generally used for palliative treatment and drainage, the catheter can also be used to deliver chemotherapeutic agents directly to the peritoneal cavity. Giving treatments this way can bathe the entire omentum in the medication
"Generally, the treatment is given in the same setting as any other chemotherapy," says Behrendt. "The medication is instilled and the patient is kept on bed rest with position changes to move the agent around in the abdomen." She sees that one of the advantages of giving chemotherapy this way is that patients generally experience fewer side effects. "The medication is less systemically absorbed using this method, and is therefore less toxic to the system," adds Behrendt.
A Stay-at-Home Mom
Ovarian cancer most often strikes women during the typical childbearing years. Many women struggle to continue their roles of wife and mother as their bodies cope with the assault of the cancer. This fight can last a few months or even years. "Palliative care can make all the difference in the way these final months play out," says Behrendt.
When Rita Cally* reached the end of her battle with ovarian cancer 10 years ago, she had a constant TPN infusion, a PDA pump for pain management, and a schedule of medical appointments that drained her time and energy. She wanted desperately to live, to see her first grandchild, to see her son marry. Every day, she prayed for one more day. Had these treatments been available to her at home, the hours she spent with her family would have been much more about being together, and much less about equipment.
"Today, we can fight a good fight against this disease," says Behrendt. Patients are more likely to be supported at home, supported in their efforts to maintain their lives as normally as possible with the least intrusion. We can help patients live their lives to the fullest for as long as they are able.