Paracentesis

Video Guide: https://www.youtube.com/watch?v=pQSsb9705LE&t=160s

 

Indications

  • Diagnostic: Evaluation of new onset ascites, or known ascites in pts with clinical decompensation, fever, abdominal pain/tenderness, HE, leukocytosis, AKI
  • Therapeutic: large volume ascites resistant to diuretics causing pt discomfort

 

Pre-Procedural considerations

  • If therapeutic, determine volume pt typically gets drained so you have enough bottles
  • 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

 

Procedural considerations

  • Ultrasound Probe: curvilinear, to identify safe pocket (~2 cm)
  • Kit: 6 Fr Safe-T-Centesis Kit
  • If only diagnostic, use 18G needle with 20-50cc syringe rather than kit
  • If high bleeding risk, use long 18 g. needle & attach to syringe instead of 6 Fr. Catheter
  • Avoid surgical scars out of concern for nearby adhesions and superficial veins
  • Z-track method: may reduce post-paracentesis ascitic fluid leakage. Once into subcutaneous tissue, move superior/inferior to allow tissue overlap.
  • 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% (VA does not allow bedside inoculation.)
  • If hernia present, have patient reduce it while draining fluid to prevent incarceration

 

Post-procedural considerations

  • Albumin for large volume (>5L): give 8 grams per liter removed
  • Ascitic leak: roll pt on opposite side; place 1 figure-of-eight stitch with 4.0 vicryl
  • Bleeding complication – Hold pressure with quick-clot and gauze for >5-10 if persistent bleeding at site; if profuse bleeding or concern for organ injury, STAT page EGS