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Paracentesis

VUMC Procedure Service Video Guide

NEJM Video Guide

Indications

  • Diagnostic: Evaluation of new onset ascites or of known ascites with concern for SBP

  • Therapeutic: tense ascites, refractory to diuretics, causing pt discomfort

Relative Contraindications

  • Significant bowel distension due to ileus or SBO, hemodynamic instability (due to large fluid shifts with LVP), DIC, infection/breakdown of skin overlying puncture site
  • Risks: abdominal wall hematoma (1%), hemoperitoneum, organ puncture / bowel perforation, infection, ascitic fluid leak

Pre-procedural considerations

  • Bleeding risk guidelines: Plts > 20k, INR < 4 (note that cirrhosis complicates INR interpretation)

  • If therapeutic, determine volume pt typically gets drained so you have enough bottles (tip: call service center to request bottles be sent to RN station if you can't find enough)

  • Labs (order before so nurse can print off labels): cell count w/diff, BF culture, BF & serum albumin, total protein; cytology if c/f malignancy; BF/serum Hct if bloody

  • Measure skin/subQ depth with US to help choose sufficiently long needle for diagnostic paras

Procedural considerations

  • Ultrasound Probe: curvilinear

  • Identify safe pocket (>2 cm deep), with no nearby bowel or adhesions

  • Local anesthesia with lidocaine all the way to peritoneum, as this is most sensitive part

  • Kit: 6 Fr Safe-T-Centesis Kit; gather cx bottles, cx bottle syringe adaptor, specimen cup

  • If only diagnostic, use 18G needle with 20-50cc syringe rather than kit

  • If high bleeding risk, use long 18G needle & attach to syringe instead of 6 Fr. Catheter

  • Avoid surgical scars out of concern for nearby adhesions and superficial veins

  • Attempt as lateral as possible to avoid inferior epigastric vessels

  • Roll patient to left or right side to promote pooling of fluid for easier/safer access

  • Inoculate culture bottles at bedside rather than sending fluid samples to lab for inoculation to increase yield 50% 80% (Note that VA does not allow bedside inoculation.)

  • If hernia present, have patient reduce it while draining fluid to prevent incarceration

Post-procedural considerations

  • Albumin (25%) for large volume (>5L fluid removal): give 8 g per liter removed, up to 50 g

  • Ascitic leak: Can try skin glue or place 1 figure-of-eight stitch with 4.0 vicryl

  • Bleeding complication: hold pressure with quick-clot and gauze for >5-10 mins if persistent bleeding at site; if profuse bleeding or concern for organ injury, STAT page EGS and/or IR