How to Perform Paracentesis

• Indications:
  • Diagnostic studies
  • Ascites
  • Spontaneous bacterial peritonitis
  • Therapeutic purposes
  • Relief of respiratory compromise
  • Relief of abdominal pain and discomfort
• Contraindications:
  • Coagulopathy (PT or PTT > 1.3)
  • Thrombocytopenia (plt < 60,000)
  • Bowel obstruction
  • Pregnancy
  • Infected skin or soft tissue at entry site
• Anesthesia:
  1% lidocaine
• Equipment:
  • Sterile prep solution
  • Sterile towels
  • Sterile gloves
  • 5-ml syringes, 20-ml syringes, 25-gauge and 22-gauge needles
  • 3-way stopcock, IV tubing
  • IV catheter (diagnostic: 20-gauge, therapeutic: 18-gauge) or long 16-gauge (CVP-type) catheter with 0.035-cm J wire
  • 500- to 1000-ml vacuum bottles and IV drip set (for therapeutic paracentesis)
• Positioning:
  Supine
  • Preferred sites of entry to prevent bleeding from epigastric vessels (see Figure 5.7)
  • Either lower quadrant (anterior iliac spine)
  • Lateral to the rectus muscle and at the level of or just below the umbilicus
  • Infraumbilically in the midline
  
  
• • The entry site should not be the site of a prior incision and should be free of gross contamination and infection.
  • The entry sites are percussed to confirm the presence of fluid and the absence of underlying bowel.
  • The patient should empty his or her bladder prior to the procedure, and/or a Foley catheter should be placed to decrease the possibility of puncturing the bladder.
• Technique Diagnostic Sampling:
  • Prepare site with sterile prep solution and drape with sterile towels.
  • Use 25-gauge needle to anesthetize skin and 22-gauge needle to anesthetize abdominal wall to peritoneum.
  • Introduce IV catheter into the abdominal cavity, aspirating as it is advanced. The needle should traverse the abdominal wall at an oblique angle to prevent persistent leak of ascites from the puncture site (see Figure 5.8).
  • When free flow of fluid occurs, the catheter should be advanced over the needle and the needle removed.
  • Draw 20–30 ml of fluid into a sterile syringe for diagnostic studies and culture.

• Technique Therapeutic Drainage:
  • Prepare site with sterile prep solution and drape with sterile towels.
  • Use 25-gauge needle to anesthetize skin and 22-gauge needle to anesthetize abdominal wall to peritoneum.
  • Introduce IV catheter into the abdominal cavity, aspirating as it is advanced. The needle should traverse the abdominal wall at an oblique angle to prevent persistent leak of ascites from the puncture site.
  • When free flow of fluid occurs, the catheter should be advanced over the needle and the needle removed. Alternatively, a CVP-type catheter with extra side holes may be placed over a guide wire using the Seldinger technique.
  • After insertion of the needle and aspiration of fluid, a J-tip guide wire is placed through the needle into the peritoneal space. The needle is removed, leaving the wire in place.
  • A stiff plastic dilator is used to dilate the tract by placing it over the wire and into the abdomen. A #11-blade scalpel can be used to make a tiny nick at the entry site as well.
  • The dilator is removed, the catheter is placed over the wire and into the abdomen, and the wire is removed.
  • Draw 20–30 ml of fluid into a sterile syringe for diagnostic studies and culture.
  • IV tubing is hooked to the catheter and to a vacuum bottle to remove a large volume of fluid.
  • Should the catheter become occluded, careful manipulation of the catheter to re-establish flow may be undertaken. Alternatively, asking the patient to turn on his or her side and again onto his or her back may also help re-establish flow. However, the needle or guide wire should not be reintroduced because of the risk of bowel injury. If less than an adequate volume is withdrawn, the catheter should be removed and replaced, possibly at another entry site.
• Complications and Management:
  • Hypotension
    • Can occur during or after procedure due to rapid mobilization of fluid from intravascular space or due to vasovagal response.
    • IV hydration can prevent and correct the hypotension in most cases.
    • 5% albumin solution or other colloid-based fluid is often used for this purpose.

• Bowel perforation
  • Rarely recognized at time of procedure
  • Can lead to infected ascites, peritonitis, and sepsis
• Hemorrhage
  • Rare, but can be caused by injury to mesentery or injury to inferior epigastric vessels.
  • Usually self-limited. Avoided by entering abdomen lateral to rectus and by correcting coagulopathy.
  • Hemodynamic instability requires laparotomy.
• Persistent ascites leak
  • Usually will seal in <2 weeks. Can result in peritonitis.
  • Skin entry site may be sutured to minimize leak.
• Bladder perforation
  • Avoided by inserting Foley catheter prior to procedure.
  • May require a period of bladder catheterization until sealed.
  • Obtain urology consult.