Indications for paracentesis (diagnostic)
Evaluation of new-onset ascites
assessment for infection
identification of malignant cells, tuberculosis, or pancreatitis
Indications for paracentesis (therapeutic)
symptomatic relief of large volume asictes
prevention of respiratory distress
Absolute contraindications
Uncorrected coagulopathy (INR over 2.0, plattelets over 50,000)
abdominal wall infection at the puncture site
acute bowel obstruction
Relative contraindications
Severe thrombocytopenia
Prior abdominal surgeries with adhesions
pregnancy
Required imaging and sterile equipment
Ultrasound machine
sterile probe cover and gel
sterile gloves, drapes, and prep kit
sterile gauze and bandages
Needles and catheters needed
18 or 21G spinal needle for diagnostic tap
5-10 french pigtail catheter for large-volume drainage
10mL and 50mL syringes
Stopcock valve
Collection and medication supplies
Vacutainer tubes and culture bottles
Lidocaine 1%
Albumin 25% if removing more than 5L
Preprocedural imaging eval (ultrasound)
Confirm presence of ascitic fluid pockeets
Identify optimal needle insertion site
Assess for bowel loops, adhesions, or abdominal wall vessels
Preprocedural imaging needed (CT or MRI if needed)
Used when ultrasound fails to localize a safe access point
detects complex ascites
Positioning of patient
Patient is in semi-recumbent (30-45 degrees) or lateral decub
Site of marking
Use ultrasound to locate fluid pocket
Avoid bowel loops, bladder, and epigastric arteries
Mark optimal insertion site
What would you modify if patient is obese?
Use a longer (3.5-5in) needle
What would you do if it was loculated ascites?
Requires multiple site attempts or catheter insertion
What would you do if the patient had coagulopathy?
Consider FFP or platelet transfusion before proceeding
What would you do if the patient had a bowel obstruction or adhesions?
Avoid midline access and use ultrasound guidance
What occurs when you puncture abdominal wall arteries?
bleeding
What can occur if the needle placement is too deep or the bowel loops are undetected?
bowel perforation
What is minimized by strict aseptic technique?
Infection
What is prevented with albumin replacement and how much albumin is needed?
Hypotension is prevented, 8g per L removed if over 5L drained
What is part of the pre-procedure preparation?
Confirm indications and obtain informed consent
Review patient labs (platelets over 50,000, INR under 2.0
Position patient in either supine or semi fowlers
identify insertion site with US
Procedural steps (sterile field and local anesthesia)
clean with clorhexidine or povidone-iodine
drape area (wearing sterile gloves)
inject lidocaine 1% subcutaneously to numb the area (make a skin wheel and go deeper to anesthetize the track)
Procedural steps (needle insertion and fluid aspiration)
Insert 18-21G needle or catheter at 45 degree angle with continuous ultrasound guidance
Advance until fluid is aspirated
If placing a catheter, thread it over the guidewire
Procedural steps (fluid collection)
draw initial 10-20mL for lab testing which includes pH, WBC count, albumin, and cytology
drained therapeutic volume slowly (max 5L per session
Post procedure steps
remove needle/catheter slowly
apply sterile dressing and monitor for bleeding or leakage
