Paracentesis

Aka: Paracentesis

advertisement

II. Indications

  1. Symptomatic relief in Cirrhotic Ascites
  2. Diagnostic study
    1. Suspected Spontaneous Bacterial Peritonitis
    2. Examine ascitic fluid for other etiology

III. 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

IV. Labs

  1. 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)
  2. 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

V. 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 for a diagnostic Paracentesis
    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

VI. Management: Post-Procedure in Cirrhosis

  1. 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
  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 or patient is hypotensive after procedure

VII. Adverse Effects

  1. Hyponatremia
  2. Hypotension
    1. Replace albumin (esp. after large volume Paracentesis)
  3. Bleeding
    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

VIII. References

  1. Swaminathan and Shoenberger (2025) Case of the Week: Management of Cirrhotic Ascites and Paracentesis, EM:Rap, 4/7/2025

Images: Related links to external sites (from Bing)

These images are a random sampling from a Bing search on the term "Paracentesis." Click on the image (or right click) to open the source website in a new browser window. Search Bing for all related images

Related Topics in Procedure

advertisement