Makindo Medical Notes

Depending on local guidance, use dullness to percussion or ultrasound (USS) to find an area of free fluid with no other structures that is posterior and dependent. Insert the needle using the Z-track method.

About

• Abdominal paracentesis is a bedside or clinic procedure where a needle is inserted into the peritoneal cavity to remove ascitic fluid.
• Diagnostic paracentesis refers to the removal of a small quantity of fluid for testing.
• Therapeutic paracentesis refers to the removal of five liters or more of fluid to relieve intra-abdominal pressure, dyspnea, abdominal pain, and early satiety.
• Routine measurement of prothrombin time and platelet count before paracentesis is not recommended (See references).

Indications

• Diagnostic paracentesis should be performed without delay to rule out spontaneous bacterial peritonitis (SBP) in all cirrhotic patients with ascites upon hospital admission.
• Uncertain etiology of ascites.

Indications for Procedure

• New onset ascites, fever, abdominal pain, increasing ascitic volume.
• Encephalopathy, renal failure, to exclude SBP.

Contraindications

• Severe uncorrectable coagulopathy (INR > 1.5, platelets < 40).
• Intestinal obstruction with bowel distension, infected abdominal wall.

Cautions

• Hyponatremia (< 126 mmol/L), poor renal function, hepatic impairment.
• Significant anemia, albumin < 20 g/L, neutropenia or immune deficiency.
• Poor patient cooperation, surgical scarring at the puncture site, large intra-abdominal mass.
• 2nd or 3rd trimester pregnancy (requires ultrasound guidance).
• Severe portal hypertension with abdominal collateral circulation.

Complications of Procedure

• Hemorrhage from injury to artery or vein—Intra-abdominal bleeding can be fatal.
• Persistent leakage of ascitic fluid at the needle puncture site.
• Hypotension, bleeding, infection, bowel perforation causing peritonitis.
• Hypotension and hyponatremia after large-volume paracentesis.

Procedure

• Introduce yourself, explain the procedure, and obtain consent.
• Check bloods for coagulopathy (INR > 1.5) or low platelets (< 50).
• Ensure the patient has urinated or insert a catheter.
• Monitor temperature, pulse, heart rate (HR), blood pressure (BP), and insert an IV cannula.

Equipment

• Ultrasound (ideally), dressing trolley & sharps bin, sterile field and dressing pack, sterile gloves, 2% Chlorhexidine swabs, analgesia.
• Needles: Orange (25G), Green (19G).
• 10ml and 20ml syringes, specimen containers, blood culture bottles, dressing.

Positioning

• Position the patient supine in bed with their head resting on a pillow.
• Select a point in the left lower quadrant, lateral to the rectus sheath.
• Clean the area with 2% Chlorhexidine and apply a sterile drape. Create a sterile field.
• Use 10ml of Lidocaine to anesthetize the skin and peritoneum with the orange needle. Then use the green needle for deeper anesthesia.

Choosing Site

• Use ultrasound guidance if available to reduce complications during large-volume paracentesis.
• If ultrasound is unavailable, puncture sites should be kept lateral to the rectus sheath, away from scars, tumor masses, distended bowel, bladder, or liver.
• Percuss the abdomen for dullness, indicating fluid. Ultrasound can further ensure a safe area.

Investigations

• Measure ascites albumin and serum albumin to calculate the serum ascites albumin gradient (SAAG).
• Send samples for microscopy, culture, and cytology.

Diagnostics

• Initial fluid analysis should include total protein concentration and SAAG calculation.
• Cytology, amylase, BNP, and adenosine deaminase tests may be considered based on clinical suspicion.
• Ascitic neutrophils >250/mm³ indicates SBP.

Post Procedure

• Administer colloid replacement, such as 20% albumin solution, after removing >5L of fluid to prevent hypotension and volume shifts.
• In patients with SBP and renal impairment, albumin infusion (1.5 g/kg initially, then 1 g/kg on day 3) is recommended.

Duration of Drain Placement

• The drain typically remains in place only for the duration of fluid removal. The length of time depends on the volume of ascitic fluid being drained and patient-specific factors:
• For large-volume paracentesis: The drain is usually removed once the fluid has been sufficiently evacuated, which is typically within a few hours to the same day.
• Volumes exceeding 8 liters: Removal of large quantities of fluid may be staged over a couple of sessions to avoid complications like hypotension or electrolyte imbalances.
• If a drain is left in place overnight, it must be monitored closely to prevent complications such as infection or persistent leakage.
• In most cases, the drain should not remain in place for more than 24 hours. Regular monitoring is essential to detect complications such as infection, hypotension, or electrolyte imbalances.