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Paracentesis

Paracentesis Learning Module

This web page is composed of six sections designed to re-familiarize practitioners with the Paracentesis procedure.

Print all the necessary documents here or at other points throughout the module.
*Note: This module does not replace medical training and must be used in conjunction with clinical judgment. Acting practitioner is ultimately responsible for the safety of procedures.

1% lidocaine without epineprhine

SoluPrep Sterile Swabs

60cc Syringe

60cc Syringe

REF 309620

Collection Bottles

Sterile Gloves

Sterile Gloves

REF 8605

Vacuum Bottle

Vacuum Bottle

REF S55120

Principle Risks

  • Major hemorrhage0.2-1.0%
  • Leakage of ascitic fluid~5.0%
  • Abdominal wall hematoma or cellulitisVariable
  • Circulatory dysfunction Variable

Rare Risks

  • Injury to intrabdominal organs~0.1 - 0.4%
  • Intra-abdominal infection ~0.2%
  • Vasovagal reaction
  • Anaesthetic/sedative reactions
  • Print Consent Form

Contraindications

  • Active skin infection over site
  • Engorged cutaneous vessels over site
  • Extremis
  • Midline scars
  • Disseminated Intravascular Coagulation

Precautions

  • INR > 1.5
  • Platelet < 50,000/mm3
  • Organomegaly, bowel obstruction, intra-abdominal adhesions or distended urinary bladder
    • Place NG tube to decompress bowel if obstruction
    • Place Foley to decompress bladder if distended

There are no absolute contraindications for paracentesis, only parameters that increase the risk

Many patients have a degree of coagulopathy and/or thrombocytopenia. Routine administration of FFP for stable coagulopathy is not recommended

Essential Investigations

  • Cell Count and Differential
  • Culture
    +
  • Fluid Albumin
  • Serum Albumin
    +
  • Cytology
    +

Targeted Investigations

  • Flow Cytometry
    +
  • AFB
    +
  • Total protein, LDH, glucose
    +
  • Triglycerides
    +
  • Amylase
    +
Print Procedure Note

1Positioning

  • Patient should be supine in bed with his/her head slightly elevated
  • The full abdomen should be exposed

2Landmark manually

  • Percuss for dullness to demarcate ascites
  • Landmark should be in the left or right lower quadrant
    • Approximately 2 cm medial and 2-4 cm superior to the anterior superior iliac spine
    • Needle MUST be inserted lateral to rectus sheath

3Visualize the effusion and remark needle insertion site

4Sterilizing and anaesthetizing

  • Sterilize the area 3 times utilizing antiseptic
  • Dress with sterile gloves and apply a sterile drape
  • With a 25 gauge needle, inject a ‘wheel’ of lidocaine into the dermis overlying the prospective needle insertion site
  • With a 20 gauge needle, anaesthetize the deeper tissues, intermittently aspirating, until pleural fluid is obtained

5Introduce the catheter device

  • Use a scalpel to create a small nick in the skin and subcutaneous tissue where you will insert your paracentesis needle
  • Introduce your catheter device where the chest wall has been previously anaesthetized utilizing the ‘Z-tract’ technique; intermittently aspirate while advancing until pleural fluid is obtained
  • Advance the plastic catheter (without the needle component) until the black/blue demarcating line is no longer visible

6Obtaining fluid

  • Turn the stopcock to the lock position and attach a 60 cc syringe.
  • Turn the stopcock 90 degrees; withdraw fluid into the syringe and divide into specimen bottles (including aerobic/anaerobic bottles)
  • For therapeutic paracenteses, attach a vacuum bottle to drain additional ascitic fluid

7Caution

  • For large volume paracentesis (i.e. greater than 5-6 L), consider administration of albumin
    • Dose: 6-8g IV albumin per litre of peritoneal fluid removed
  • Stop/pause the procedure if patient develops significant abdominal pain, hemodynamic instability, or signs/symptoms of vasovagal reaction

8Post procedure care

  • Turn stop-cock into locked position before withdrawing catheter device
  • Place clean bandage over procedural site
  • Order post-procedure vitals
  • Documentation sheet must be in the chart!

9Caution

All specimens should be hand-delivered to their destinations
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