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