Paracentesis

See Also

Indications

Diagnostic
1. Suspected Spontaneous Bacterial Peritonitis
2. New onset Ascites evaluation
Therapeutic
1. Symptomatic relief in Cirrhotic Ascites (respiratory compromise, Abdominal Distention)
2. Hepatorenal Syndrome (adjunctive management)

Contraindications

Absolute Contraindications
1. Disseminated Intravascular Coagulation
2. Entry site with abdominal wall infection
3. Acute Abdomen requiring exploratory surgery
Relative Contraindications
1. Bowel Obstruction
2. Pregnancy
3. Multiple prior abdominal surgeries
4. Cirrhosis with Fibrinogen <100 (consider replacement with 1 pack Cryoprecipitate, 2 packs if weight >80 kg)
5. INR >3 on Warfarin
6. Platelet Count <20,000
Conditions which do NOT independently contraindicate emergent Paracentesis (hold medications if possible prior to elective procedures)
1. Direct Oral Anticoagulant (DOAC)
2. Antiplatelet agents (e.g. Aspirin, Clopidogrel)

Labs

Labs (e.g. CBC, INR, PTT) are not required prior to routine therapeutic Paracentesis (per ACG, AGA)
1. Paracentesis is a procedure at low risk of bleeding complications
2. May consider labs when there is a change in clinical status (e.g. new weakness)
May consider Platelet Transfusion if Platelet Count<20,000
1. Transfuse 6 pack of Platelets before Paracentesis
2. Consider Diphenhydramine 50 mg IV, 30 min before Platelets

Procedure

Equipment
1. Skin Preparation (Chlorhexidine swabs, sterile drape)
2. Angiocatheter 3 to 3.5 inches (or Caldwell needle, DPL needle or paracentersis kit needle)
  1. In diagnostic Paracentesis only, a 22 gauge spinal needle may be used instead
3. Lidocaine 1% via 10 ml syringe and 27 gauge needle for skin Anesthesia
4. Syringe 60 ml for diagnostic fluid collection
5. Suction tubing
6. Evacuated containers
7. Blood Culture bottles
8. Cardiac phased array Ultrasound probe with sterile sheath cover and sterile gel outside the probe
Preparation
1. Patient at semi-recumbent position to 30 degrees head up (reverse Trendelenburg)
2. Patient empties Bladder before procedure (or place Foley and empty Bladder before procedure)
  1. Primarily for midline approach
Sites
1. Avoid the rectus sheath
  1. Risk of inferior epigastric artery puncture and Hemorrhage risk
2. Midline at Linea Alba
  1. Midline at approximately 2 cm below Umbilicus
  2. Patient in semi-recumbent position
  3. Two probe Ultrasound technique is safest
    1. Curvilinear probe or phased array probe identifies the largest Ascites pocket
    2. Linear array probe with doppler color identifies the inferior epigastric artery
    3. Barsuk (2018) J Hosp Med 13(1):30-3 +PMID: 29073312 [PubMed]
3. Lower quadrants (RLQ or LLQ) lateral to rectus sheath
  1. Perform under Ultrasound guidance
  2. Patient in semi-recumbent position with left lateral tilt
  3. Left lower quadrant is preferred if adequate fluid
    1. Sigmoid in LLQ is mobile in contrast to the fixed position of the cecum in RLQ
Prepare site
1. Clean and prep site well (e.g. Chlorhexidine)
  1. Spontaneous Bacterial Peritonitis risk
2. Local 1% Lidocaine Anesthetic via 27 gauge needle
  1. Anesthetize the skin, soft tissue and deep to peritoneum
Paracentesis
1. Use Angiocatheter 3 to 3.5 inches (or Caldwell needle, DPL needle or paracentersis kit needle)
  1. Consider pre-dilating needle track with an 18 gauge needle
2. Consider Z-Tracking needle on entry into Abdomen
3. Needle entry is best done under Ultrasound guidance
  1. Needle insertion is perpendicular to skin and adjacent to probe
4. Advance needle until fluid aspirated
  1. Advance the needle another 1 cm
  2. Then thread the catheter over the needle into the peritoneal space
5. Collect initial 50-60 ml Ascites in syringe for diagnostic testing (see below)
6. Use vacuum bottles (evacuated containers) to drain remaining Ascites in therapeutic Paracentesis
Labs to send ascitic fluid for a diagnostic Paracentesis
1. Cytology (if malignancy suspected)
2. Cultures
  1. Rule-out Spontaneous Bacterial Peritonitis
  2. Inoculate culture bottles bedside for best yield
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

Management
Post-Procedure in Cirrhosis

Always send ascitic fluid for white cell count and Neutrophil Count (PMN Count)
1. Add culture if total white cell count >500/mm3 (or PMNs >250/mm3)
2. In Cirrhotic Ascites, 40% of patients are asymptomatic of Spontaneous Bacterial Peritonitis
Up to 4-5 liters may be safely removed per Paracentesis without albumin replacement
1. Replace albumin if >5 Liters are removed or patient is hypotensive after procedure
2. Risk of Paracentesis-induced circulatory dysfunction (PICD) with >5 Liter Paracentesis
  1. Associated with Hyponatremia, Acute Kidney Injury, and increased mortality
Salt-poor albumin replacement for >5 Liters removed (large volume Paracentesis)
1. Albumin 25% 50 cc bottle IV
2. Dosing
  1. Replace albumin 8-10 grams per liter of ascitic fluid removed OR
  2. One 25 gram bottle of albumin for every 1.5L of ascitic fluid removed

Complications

Major
1. Bowel or Bladder perforation
2. Hepatorenal Syndrome
3. Paracentesis-induced circulatory dysfunction (PICD)
  1. Associated with Hypotension, Acute Kidney Injury, Hyponatremia
  2. Replace albumin (esp. after large volume Paracentesis)
4. Hemoperitoneum
  1. Any blood in peritoneal fluid should soon clear as Paracentesis continues
  2. Persistent blood in peritoneal fluid is abnormal
    1. Stop procedure and withdraw catheter
    2. Obtain serial Hemoglobins
    3. Consider CTA Abdomen
Minor
1. Persistent ascitic leak from Paracentesis site
  1. Consider figure-of-eight Suture at puncture site (above and below the puncture)
  2. Tissue Adhesive (e.g. Dermabond)
    1. Dry the site first with oxygen flow via Nasal Cannula
    2. Dermabond may also be injected 1 cm into the puncture track
2. Soft tissue infection at Paracentesis site
3. Abdominal wall Hematoma

References

Esherick (2025) Paracentesis, Hospital Procedures Course
Swaminathan and Shoenberger (2025) Case of the Week: Management of Cirrhotic Ascites and Paracentesis, EM:Rap, 4/7/2025