The LSUHSC New Orleans Emergency Medicine Interest Group Presents The Student Procedure Manual

Paracentesis

by Aruna Akundi with
Wayne Berkowitz

Indications
Contraindications (all relative)
Prerequisites
Equipment
Procedure
Follow-up
Complications
References

Indications

• Diagnostic tool to determine the etiology of ascites fluid, once it has been proven to exist by physical exam and/or ultrasound, and to ascertain if infection is present.
  
• Therapeutic intervention to drain large volumes of abdominal ascites for improving pulmonary function or diminishing abdominal pain from distention.

Contraindications (all relative)

• Prothrombin Time prolonged > 6 seconds over control and a platelet count < 60,000.
  
• Some discount coagulopathy as a relative contraindication, if paracentesis is performed in the relatively avascular midline.
  
• Distended bowel- risk of bowel perforation especially in obstructed bowels and in patients with possible adhesions from previous abdomen surgery.
• Pregnancy
  
• Uncooperative patient

Prerequisites

• Pt should have an empty bladder. If pt cannot accomplish this', then a Foley catheter must be placed
  
• Pt's prothrombin time, partial thromboplastin time, and platelet count should be evaluated and corrected due to risk of hemorrhage.

Equipment

• Antiseptic solution and drapes
  
• 1 % Lidocaine
  
• 18- or 20 gauge needle and syringe

Procedure

1. Place patient in supine or lateral decubittis position.
   
2. The ideal puncture site is in the left lower quadrant of the abdomen, lateral to the rectus abdominis muscle , in the midclavicular line, inferior to the umbilicus.
   
3. Alternate sites may be preferred depending on the location of the fluid and the purpose of the tap.
   
4. Point of entry should remain lateral to the rectus abdominis muscle to avoid injury to the inferior epigastric artey and vein.
   
5. Avoid the upper abdominal quadrants in case of undetected hepatosplenomegaly.
   
6. Avoid visible, collateral venous channels (caput medusa) on the abdominal wall.
   
7. Avoid known sites of abdominal surgery where adhesions may be present.
   
8. After appropriate sterile preparation, infiltrate 1% Lidocaine subcutaneously to the peritoneum.
   
9. Refer to the Intramuscular Injection procedure to perform a "Z seal" to prevent persistent ascitic leakage at site.
   
10. Insert an 18- or 20- gauge short beveled spinal needle attached to a syringe through the abdominal wall. Different sizes and types of needles or catheters may be used depending on the purpose of paracentesis.
    
11. Withdraw at least 50ml of ascitic fluid for adequate study. Some situations may necessitate larger quantities ranging from I to 3 liters, as in tense ascites.

*Note: Special paracontosis needles, "needle-over-catheter", can be used for this procedure and are preferred in that the risk of parenchymal injury is reduced.

Follow-up

• Ascites fluid can be sent for lab analysis: cell count (heparinized tube) and differential, total protein, glucose, specific gravity, amylase, LDH, bacterial and mycobacterial cultures and cell block pathology (heparinized tube).

Complications

• Hemorrhage
  
• Persistent ascitic leak
  
• Intestinal or urinary bladder perforation with associated peritonitis and infection
  
• Transient hypot6nsion in pts with large-volume chronic abdominal ascites such as that secondary to hepatic cirrhosis or ovarian carcinoma
  
• Intraperitoneal air

References

1. Glauser JM. Paracentesis. In: Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1991: 674-678.
   
2. Napolitano LM. Paracentesis. In: Rippe JM, et al. eds. Procedures and Techniques in Intensive Care Medicine. Philadelphia, Pa: Little, Brown and Co; 1995: 207-209.