Paracentesis

External Video for paracentesis.

Indications

Diagnostic: New onset ascites (etiology) or possibility of SBP in patient with ascites

Therapeutic: Symptomatic tense ascites with cardiorespiratory or gastrointestinal symptoms

Contraindication

Absolute: overlying site infection

Relative: coagulopathy (INR>1.5, Plt<50) although routine INR and FBC not indicated prior to procedure and replacement only if signs of bleeding; anatomical – adhesions, neuropathic bladder, suggest US prior to needle insertion to identify areas of anatomical concern

Alternative

Diagnostic alternatives are limited as fluid analysis is the only effective way to determine etiology and identify SBP. Empirical treatment of SBP would be challenging and have significant long term morbidity associated with it. Alternative to large volume paracentesis for large volume ascites would be symptomatic.

Complications

Common

Local

Leakage of ascitic fluid(single suture)

Haematoma

Systemic

Post paracentesis circulatory dysfunction(PCD) following LVP(large volume paracentesis >5L)

Uncommon

Infection (local or intraperitoneal) rare<0.2%

Bowel perforation - rare with US

Vessel perforation - mitigated by point of entry

PROCEDURE

Area

  • Any bed, sufficient space for procedure and asepsis

Staff

  • Assistant useful but not essential

Equipment

  • PPE – sterile gloves
  • Antiseptic
  • Local anaesthetic - lignocaine+/-adrenaline 1% 10mls
  • Paracentesis kit - drape, syringe for local(5mls), syringe for sample(20mls), needle for LA injection (25G or 23G)
  • Sample collection – EDTA tube, blood culture bottles, urine container
  • Leur lock drainage bag
  • 12F Dwellcath needle
  • 20% albumin if LVP planned

Monitoring

  • HR and BP(5-10min cycle) monitoring, clinical state

Sequence

Position patient – semi-recumbent 20-30 degrees

U/S prior to procedure to assess optimal location of entry – R or LIF lateral to the inferior epigastric vessels; mark with pen/indent skin

Scrub, don gloves and apply antiseptic

While drying setup workspace

Apply drape

Consider real time U/S(requires sterile probe cover)

Inject local anaesthetic under skin

Advance needle slightly, aspirate and inject subcutaneously

Allow 30-60 seconds for LA to start working

Puncture skin with small needle included with 12F Dwellcath

Attach 20ml syringe to needle, insert perpendicular to skin, apply –ve pressure with syringe

Advance needle until aspirating ascites

Slide the plastic cannula forward and withdraw metal needle

Attach syringe to cannula and ensure able to aspirate, collect sample

Connect 3 way connector

Attach Leur lock catheter bag

Secure cannula to skin – mesentery dressing

Allow drainage

Replace 100mls of 20% albumin for every 3L of fluid removed

If drainage stops, slowly withdraw needle as bowel/structures might be resting against ti

NEVER INSERT NEEDLE DEEPER AFTER INITIAL INSERTION

If no drainage returns continue to withdraw and remove

Apply dressing

If ongoing leakage pressure or a single suture insertion

If bleeding complication consider checking INR and Plt and replace products if ongoing AND clinically significant

Tips and tricks

Check (fluid amount and adhesions) the insertion point with US prior to commencement with patient in position

Dot advance the cannula once filed non-sterile

Use the Z-line insertion technique to decrease leakage

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