II. Indications
- Diagnostic
- Suspected Spontaneous Bacterial Peritonitis
- New onset Ascites evaluation
- Therapeutic
- Symptomatic relief in Cirrhotic Ascites (respiratory compromise, Abdominal Distention)
- Hepatorenal Syndrome (adjunctive management)
III. Contraindications
- Absolute Contraindications
- Disseminated Intravascular Coagulation
- Entry site with abdominal wall infection
- Acute Abdomen requiring exploratory surgery
- Relative Contraindications
- Bowel Obstruction
- Pregnancy
- Multiple prior abdominal surgeries
- Cirrhosis with Fibrinogen <100 (consider replacement with 1 pack Cryoprecipitate, 2 packs if weight >80 kg)
- INR >3 on Warfarin
- Platelet Count <20,000
- Conditions which do NOT independently contraindicate emergent Paracentesis (hold medications if possible prior to elective procedures)
- Direct Oral Anticoagulant (DOAC)
- Antiplatelet agents (e.g. Aspirin, Clopidogrel)
IV. Labs
- Labs (e.g. CBC, INR, PTT) are not required prior to routine therapeutic Paracentesis (per ACG, AGA)
- Paracentesis is a procedure at low risk of bleeding complications
- May consider labs when there is a change in clinical status (e.g. new weakness)
- May consider Platelet Transfusion if Platelet Count<20,000
- Transfuse 6 pack of Platelets before Paracentesis
- Consider Diphenhydramine 50 mg IV, 30 min before Platelets
V. Procedure
- Equipment
- Skin Preparation (Chlorhexidine swabs, sterile drape)
- Angiocatheter 3 to 3.5 inches (or Caldwell needle, DPL needle or paracentersis kit needle)
- In diagnostic Paracentesis only, a 22 gauge spinal needle may be used instead
- Lidocaine 1% via 10 ml syringe and 27 gauge needle for skin Anesthesia
- Syringe 60 ml for diagnostic fluid collection
- Suction tubing
- Evacuated containers
- Blood Culture bottles
- Cardiac phased array Ultrasound probe with sterile sheath cover and sterile gel outside the probe
- Preparation
- Sites
- Avoid the rectus sheath
- Risk of inferior epigastric artery puncture and Hemorrhage risk
- Midline at Linea Alba
- Midline at approximately 2 cm below Umbilicus
- Patient in semi-recumbent position
- Two probe Ultrasound technique is safest
- Curvilinear probe or phased array probe identifies the largest Ascites pocket
- Linear array probe with doppler color identifies the inferior epigastric artery
- Barsuk (2018) J Hosp Med 13(1):30-3 +PMID: 29073312 [PubMed]
- Lower quadrants (RLQ or LLQ) lateral to rectus sheath
- Perform under Ultrasound guidance
- Patient in semi-recumbent position with left lateral tilt
- Left lower quadrant is preferred if adequate fluid
- Sigmoid in LLQ is mobile in contrast to the fixed position of the cecum in RLQ
- Avoid the rectus sheath
- Prepare site
- Clean and prep site well (e.g. Chlorhexidine)
- Local 1% Lidocaine Anesthetic via 27 gauge needle
- Anesthetize the skin, soft tissue and deep to peritoneum
- Paracentesis
- Use Angiocatheter 3 to 3.5 inches (or Caldwell needle, DPL needle or paracentersis kit needle)
- Consider pre-dilating needle track with an 18 gauge needle
- Consider Z-Tracking needle on entry into Abdomen
- Needle entry is best done under Ultrasound guidance
- Needle insertion is perpendicular to skin and adjacent to probe
- Advance needle until fluid aspirated
- Advance the needle another 1 cm
- Then thread the catheter over the needle into the peritoneal space
- Collect initial 50-60 ml Ascites in syringe for diagnostic testing (see below)
- Use vacuum bottles (evacuated containers) to drain remaining Ascites in therapeutic Paracentesis
- Use Angiocatheter 3 to 3.5 inches (or Caldwell needle, DPL needle or paracentersis kit needle)
- Labs to send ascitic fluid for a diagnostic Paracentesis
- Cytology (if malignancy suspected)
- Cultures
- Rule-out Spontaneous Bacterial Peritonitis
- Inoculate culture bottles bedside for best yield
- Neutrophils (PMNs)
- Suggests Spontaneous Bacterial Peritonitis if >250/mm3 in Cirrhotic Ascites
- Serum-to-Ascites Albumin Gradient (SAAG)
- Subtract ascitic fluid albumin from Serum Albumin
- SAAG >1.1 g/dl suggests Portal Hypertension
VI. Management: Post-Procedure in Cirrhosis
- Always send ascitic fluid for white cell count and Neutrophil Count (PMN Count)
- Add culture if total white cell count >500/mm3 (or PMNs >250/mm3)
- 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
- Replace albumin if >5 Liters are removed or patient is hypotensive after procedure
- Risk of Paracentesis-induced circulatory dysfunction (PICD) with >5 Liter Paracentesis
- Associated with Hyponatremia, Acute Kidney Injury, and increased mortality
- Salt-poor albumin replacement for >5 Liters removed (large volume Paracentesis)
- Albumin 25% 50 cc bottle IV
- Dosing
- Replace albumin 8-10 grams per liter of ascitic fluid removed OR
- One 25 gram bottle of albumin for every 1.5L of ascitic fluid removed
VII. Complications
- Major
- Bowel or Bladder perforation
- Hepatorenal Syndrome
- Paracentesis-induced circulatory dysfunction (PICD)
- Associated with Hypotension, Acute Kidney Injury, Hyponatremia
- Replace albumin (esp. after large volume Paracentesis)
- Hemoperitoneum
- Any blood in peritoneal fluid should soon clear as Paracentesis continues
- Persistent blood in peritoneal fluid is abnormal
- Stop procedure and withdraw catheter
- Obtain serial Hemoglobins
- Consider CTA Abdomen
- Minor
- Persistent ascitic leak from Paracentesis site
- Consider figure-of-eight Suture at puncture site (above and below the puncture)
- Tissue Adhesive (e.g. Dermabond)
- Dry the site first with oxygen flow via Nasal Cannula
- Dermabond may also be injected 1 cm into the puncture track
- Soft tissue infection at Paracentesis site
- Abdominal wall Hematoma
- Persistent ascitic leak from Paracentesis site
VIII. 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