Procedure

Paracentesis

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Paracentesis

  • Indications
  1. Symptomatic relief in Cirrhotic Ascites
  2. Diagnostic study
    1. Suspected Spontaneous Bacterial Peritonitis
    2. Examine ascitic fluid for other etiology
  • General
  1. Remove up to 4-5 L ascitic fluid
  2. Salt-poor albumin
    1. Indicated post-procedure if >5 liters removed
    2. Preparation: 25% 50 cc bottle IV
    3. Dosing
      1. 1 bottle for every 1.5L of ascitic fluid removed or
      2. 8-10 grams per liter of fluid removed
  • Labs
  1. Prior to procedure
    1. Complete Blood Count
    2. ProTime
    3. Partial Thromboplastin Time
  2. If Platelets <40,000 then
    1. Transfuse 6 pack of Platelets before Paracentesis
    2. Consider Benadryl 50 mg IV, 30 min before Platelets
  • Procedure
  1. Preparation
    1. Place Foley and empty Bladder before procedure
    2. Patient at 30 degrees head up (reverse Trendelenburg)
  2. Sites
    1. Avoid the rectus sheath
    2. Midline at Linea Alba
      1. Midline at approximately 2 cm below Umbilicus
    3. Lower quadrants (RLQ or LLQ) lateral to rectus sheath
      1. Perform under Ultrasound guidance
  3. Prepare site
    1. Clean and prep site well
      1. Spontaneous Bacterial Peritonitis risk
    2. Local 1% Lidocaine Anesthetic
  4. Paracentesis
    1. Use 22 gauge needle with catheter
    2. Consider Z-Tracking needle on entry into Abdomen
    3. Use vacuum bottle to apply suction
  5. Labs to send ascitic fluid
    1. Cytology (if malignancy suspected)
    2. Cultures (rule-out SBP)
      1. Rule-out Spontaneous Bacterial Peritonitis
    3. Neutrophils (PMNs)
      1. Suggests Spontaneous Bacterial Peritonitis if >250/mm3 in Cirrhotic Ascites
    4. Serum-to-Ascites Albumin Gradient (SAAG)
      1. Subtract ascitic fluid albumin from Serum Albumin
      2. SAAG >1.1 g/dl suggests Portal Hypertension
  1. Always send ascitic fluid for culture and PMN Count
    1. In Cirrhotic Ascites, 40% of patients are asymptomatic of Spontaneous Bacterial Peritonitis
  2. Up to 4-6 liters may be safely removed per Paracentesis without albumin replacement
    1. Risk of Paracentesis-induced circulatory dysfunction (PICD) with >6 Liter Paracentesis
    2. Replace albumin if >6 Liters are removed
  • Adverse Effects
  1. Hypotension
  2. Hyponatremia
  3. Bleeding