Shreya Sengupta, MD
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Abdominal paracentesis with appropriate ascitic fluid analysis is one of the most rapid and cost-effective methods of diagnosing the cause of ascites.1 Paracentesis is safely and routinely performed in both the inpatient and outpatient settings.
1. Evaluation of new-onset ascites
2. Evaluation for spontaneous bacterial peritonitis in all patients with ascites and abdominal pain, fever, unexplained encephalopathy, leukocytosis, worsening renal function, or gastrointestinal bleeding
3. Evaluation for subclinical infection in all patients with ascites requiring hospitalization
4. Treatment of symptomatic ascites2
Coagulopathy should preclude paracentesis only when there is clinically evident fibrinolysis or clinically evident disseminated intravascular coagulation.1 There is no data to suggest coagulation parameter cutoffs beyond which paracentesis should be avoided as the incidence of clinically significant bleeding in patients with underlying liver disease is low.1,2 Paracentesis should be performed with caution in pregnant patients or in patients with organomegaly, bowel obstruction, intra-abdominal adhesions, or a distended urinary bladder. The paracentesis catheter should avoid sites of cutaneous infection, visibly engorged cutaneous vessels, surgical scars, or abdominal wall hematomas.2
PREPARATION OF PATIENT
1. Sterile gloves and face shield
2. Skin preparation solution (i.e., chlorhexidine, iodine solution; sterile gauze)
3. Draping towels
4. Local anesthetic (lidocaine, 1%) and needles
5. Syringes: 10 mL, 50 mL
6. Paracentesis needles:
a. No. 16, 18, 20, or 22 gauge
b. Spinal needle (No. 18, 20 gauge) for obese patients
c. Caldwell needle, long angiocath
7. Sterile specimen tubes
8. Blood culture bottles for bedside inoculation, if infection suspected
9. Vacutainer or wall suction setup for large-volume paracentesis
1. Position the patient supine with the head slightly elevated to allow fluid to accumulate in the lower abdomen.
2. Identify the point of aspiration on either flank, usually two finger breadths cephalad and two finger breadths medial to the anterior superior iliac spine. An alternative location is in the midline midway between the umbilicus and pubic bone. Although the midline is relatively avascular, the abdominal wall in the left lower quadrant is thinner with a larger pool of fluid than in the midline.3 Be careful to avoid abdominal wall scars, as bowel may be fixed to the wall, and visible collaterals. The rectus muscles should also be avoided because the epigastric arteries travel within the rectus sheath (Fig. 50.1).
3. Confirm dullness to percussion in the site selected for needle entry. If available, use bedside ultrasonography to find an appropriate pocket of ascites fluid that does not contain loops of bowel or solid organs. Mark the chosen entry site with a skin-marking pen. At many institutions, radiology can be consulted to mark the site with largest fluid pocket.
4. Put on sterile gloves.
5. Sterilize the site with an iodine solution or with chlorhexidine using small to large circles to clean the area.
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