Paracentesis

Paracentesis Reference Links

• Paracentesis Fluid Interpretation

Indications:

• Diagnostic
  • Determine the cause of new onset ascites, ascites of unknown origin, or suspected malignant ascites
  • Suspicion of bacterial peritonitis in a patient with known ascites with associated pyrexia, hypotension, tachycardia or encephalopathy.
• Therapeutic
  • Remove excess intraperitoneal fluid to assist respiration and provide symptomatic relief.

Contraindications:

• Problems at proposed puncture site
  • Local skin infection/cellulitis; abdominal hernia; caput medusae or superficial veins
• Suspected abdominal adhesions or loculated collections of fluid
• Significant bowel distension.
• Uncooperative patient
• Uncorrected bleeding diathesis
  • Note: Paracentessis can be safely performed with INR <8 and platelets >20
  • Preprocedure bloods are not routine for those undergoing repeated therapeutic paracentesis

Controversy:

• Volume replacement and hemodynamic shifts following paracentesis are highly controversial.
  • Colloid infusion is considered strictly optional for paracentesis of more than 5 L and is generally no longer recommended for paracentesis of lesser volume
  • “6L has been removed in 15 min without negative consequences”
    • Vila MC, Coll S, Sola R, et al: Total paracentesis in cirrhotic patients with tense ascites and dilutional hyponatremia.  Am J Gastroenterol 1999; 94:2219. [Reference]
    • Runyon BA: Management of adult patients with ascites caused by cirrhosis.  Hepatology 1998; 27:264. [Reference]
    • Runyon BA: Patient selection is important in studying the impact of large-volume paracentesis on intravascular volume.  Am J Gastroenterol 1997; 92:371.

Handy Hints:

• USS guided paracentesis should be used in patients who are pregnant, have multiple abdominal scars or a history of bowel adhesions
• Best site of entrance for repeat paracentesis and therapeutic volume to be removed is determined by the patient’s prior experience, so these should be asked of the patient
• No aspiration
  • Re-percuss the abdomen and try again. If still unsuccessful, request USS.
• No drainage
  • Kinked or blocked tube: untwist and flush with sterile saline.
  • Drain not secured properly and no longer in peritoneum: remove drain and re-site.