Paracentesis is the removal of fluid from the peritoneal cavity through the use of a needle for either therapy (to relieve patient symptoms) or diagnosis (to determine causes or complications of ascites). The procedure is generally well-tolerated and simple to perform, especially with the general availability of bedside ultrasound.

DIAGNOSTIC

 To analyze abnormal fluid collection in peritoneal space to determine etiology or pathologic conditions (e.g., infection). Most commonly for diagnosis of spontaneous bacterial peritonitis (SBP).

THERAPEUTIC

 To evacuate ascites for symptomatic relief, usually of shortness of breath and discomfort from abdominal distention. Paracentesis decreased in-hospital mortality 24% when done early (within 24 h of admission) as opposed to later in one large study (Orman ES et.al).

CONTRAINDICATIONS

 Absolute Contraindications

    Disseminated intravascular coagulopathy

 Relative Contraindications

    Intra-abdominal adhesions

    Abdominal wall cellulitis

    In second or third trimester pregnancy, an open supraumbilical or ultrasound-assisted approach is preferred

    Exercise caution in coagulopathic or renal failure patients.

LANDMARKS

 Preferred approach: 3 cm superior and medial to the anterior superior iliac spine

 Stay lateral to the rectus sheath to avoid the inferior epigastric artery. The abdominal wall is also thinner in this location.

 Alternative approach: 2 cm below the umbilicus in the midline. Avoid if the patient has a midline surgical scar.

TECHNIQUE

 Supplies

    Bedside ultrasound machine, if available

    Culture bottles and tubes for cell count, Gram stain, and albumin

    Have a low threshold to send a cell count with differential, even if the tap is being performed for primarily therapeutic purposes.

    Commercial paracentesis kits containing rigid plastic sheath cannula, if available

 If a kit is not available, then the following supplies should be obtained:

    Iodine or chlorhexidine swabs

    Sterile 4 × 4 gauze

    Sterile towels or fenestrated drape

    Sterile and nonsterile gloves

    Sterile 60-cc syringes for collecting fluid sample

    10-cc syringe for anesthesia

    1% to 2% lidocaine (preferably with epinephrine)

    Skin anesthesia needles

       25- or 27-gauge 1.5-inch needle (local anesthesia)

       20- or 22-gauge 1.5-inch needle (local anesthesia)

       18-gauge needle (inoculating specimen tubes)

    Paracentesis needles

       22-gauge needle for diagnostic taps, 18-gauge needle for therapeutic taps

       1.5 inch should be sufficient, may need 3.5 inch (spinal needle) for obese patients

    Adhesive bandage

 Patient Preparation

    Direct the patient to urinate or empty the bladder via urinary catheterization

    Ultrasonography (preferred, but not essential). Bedside ultrasonography is used to verify that the chosen site has a large fluid pocket with no bowel adhesions.

    Sterilize the area where the needle will be inserted with copious povidone–iodine solution or similar surgical prep

    Drape the area with sterile towels or sterile fenestrated drape

 Patient Positioning

    If there is a large amount of ascites, the patient may be placed in a supine position with the head of the bed slightly elevated

    Patients with lesser amounts of ascites may be placed in a lateral decubitus position for optimal pooling of fluid. Left lateral decubitus may be ideal, as this is generally the most fluid-rich area.

 Analgesia

    Produce local anesthesia using up to 5 mg/kg of 1% lidocaine with epinephrine

    Raise a subcutaneous wheal with a small-bore (25- or 27-gauge) needle, and then generously infiltrate the deeper tissues in the area of the paracentesis needle’s eventual passage using a longer, larger-bore needle

    Anesthetize to the depth of the peritoneum

 Needle Insertion

    Standard-sized (1.5-inch) metal needle will be sufficient in most cases

       A longer (3.5-inch) spinal needle may be necessary in obese patients

       For diagnostic taps, a smaller-gauge (22–20 gauge) needle should be utilized to decrease the chance of postprocedural fluid leak

       For therapeutic taps, a larger (18 gauge) needle may be used to hasten fluid evacuation

    Attach needle to a 60-mL syringe

    Advance the needle in slow, controlled 5-mm increments with continuous gentle aspiration of the syringe. A “Z-tract” method may be employed to decrease the risk of postprocedural fluid leak (FIGURE 28.1).

       Overlying skin is pulled by an assistant or by the non–needle bearing hand 2 cm in the caudal direction

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