Paracentesis¶
Indications¶
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Diagnostic: Evaluation of new onset ascites or of known ascites with concern for SBP
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Therapeutic: tense ascites, refractory to diuretics, causing pt discomfort
Relative Contraindications¶
- Significant bowel distension due to ileus or SBO, hemodynamic instability (due to large fluid shifts with LVP), DIC, infection/breakdown of skin overlying puncture site
Consent¶
- Risks: abdominal wall hematoma (1%), hemoperitoneum, organ puncture / bowel perforation, infection, ascitic fluid leak
Pre-procedural considerations¶
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Bleeding risk guidelines: Plts > 20k, INR < 4 (note that cirrhosis complicates INR interpretation)
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If therapeutic, determine volume pt typically gets drained so you have enough bottles (tip: call service center to request bottles be sent to RN station if you can't find enough)
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Labs (order before so nurse can print off labels): cell count w/diff, BF culture, BF & serum albumin, total protein; cytology if c/f malignancy; BF/serum Hct if bloody
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Measure skin/subQ depth with US to help choose sufficiently long needle for diagnostic paras
Procedural considerations¶
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Ultrasound Probe: curvilinear
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Identify safe pocket (>2 cm deep), with no nearby bowel or adhesions
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Local anesthesia with lidocaine all the way to peritoneum, as this is most sensitive part
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Kit: 6 Fr Safe-T-Centesis Kit; gather cx bottles, cx bottle syringe adaptor, specimen cup
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If only diagnostic, use 18G needle with 20-50cc syringe rather than kit
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If high bleeding risk, use long 18G needle & attach to syringe instead of 6 Fr. Catheter
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Avoid surgical scars out of concern for nearby adhesions and superficial veins
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Attempt as lateral as possible to avoid inferior epigastric vessels
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Roll patient to left or right side to promote pooling of fluid for easier/safer access
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Inoculate culture bottles at bedside rather than sending fluid samples to lab for inoculation to increase yield 50% 80% (Note that VA does not allow bedside inoculation.)
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If hernia present, have patient reduce it while draining fluid to prevent incarceration
Post-procedural considerations¶
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Albumin (25%) for large volume (>5L fluid removal): give 8 g per liter removed, up to 50 g
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Ascitic leak: Can try skin glue or place 1 figure-of-eight stitch with 4.0 vicryl
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Bleeding complication: hold pressure with quick-clot and gauze for >5-10 mins if persistent bleeding at site; if profuse bleeding or concern for organ injury, STAT page EGS and/or IR