Center for Clinical Procedures & Simulation Internal Medicine Residency Program

Paracentesis

INDICATIONS

  • Characterization of newly diagnosed ascitic fluid into portal/non-portal hypertensive causes
  • Diagnosis of spontaneous bacterial peritonitis Replica Handbags
  • Diagnosis of Intra-abdominal malignancy with suspected peritoneal involvement

CONTRAINDICATIONS

  • Severe coagulopathy, although usually can be safely done
  • Acute abdomen requiring surgery
  • Severe bowel distention
  • Overlying skin infection
  • Pregnancy without ultrasound guidance
  • Distended bladder without ultrasound guidance

RISKS

  • Bladder perforation
  • Intestinal perforation
  • Major vessel perforation (rare)
  • Abdominal wall hematoma (2%)
  • Wound infection
  • Peritonitis (theoretical but very rare)

TECHNIQUE

  1. Obtain informed consent (see risks)
  2. Midline approach in the infra-umbilical region is preferred panerai replica due to absence of vasculature. If there was previous surgery here, use a right or left lower quadrant approach. Use ultrasound guidance to localize a fluid pocket that is void of bowel and adhesions.
  3. Have the patient empty his bladder or place a Foley catheter; be sure bladder is not distended.
  4. Position the patient supine or with the head slightly elevated.
  5. Prep the skin below the umbilicus or lower quadrant with povidone-iodine solution and wait a couple minutes. Place cutout drape over area.
  6. Using the 25 ga needle, anesthetize the skin and with the 22 ga needle anesthetize the subcutaneous tissue about 2-3 cm below the umbilicus or in the lateral quadrants (making sure you are lateral to the rectus sheath that contains the inferior epigastric arteries. Attempt to enter the peritoneum, injecting and withdrawing on the syringe as you go. When the peritoneum is entered, fluid will return and you can inject 2cc of lidocaine into the peritoneal cavity; gradually withdraw the needle.
  7. Make a small nick with a number 11 blade at the puncture site.
  8. Using the thora/paracentesis needle with overlying catheter attached to a 60 mL syringe, advance while intermittently pulling back on the plunger.
  9. When the peritoneal cavity is entered, fluid will return. At this point the tip of the needle is in, but the catheter is still ~1cm further back, so advance the entire assembly about 1cm further. While holding the needle stationary, advance catheter into the peritoneal cavity and then withdraw the needle.
  10. Reattach 60cc syringe and fill with ascitic fluid for analysis and transfer this fluid to the 3 sample tubes and secure the tops and label with patient sticker. If cytology is needed, take an additional 100cc of fluid in the large syringe for the lab to "spin-down" and increase sensitivity of the cytology.
  11. If vacuum bottles are to be used, they can be attached via tubing to the catheter directly at this point
  12. When the flow of fluid stops, slowly pull back the catheter to pull it off of the bowel that has been "sucked" up onto the tip. It is sometimes helpful to clamp off the suction as you retract the catheter so that it doesn't just pull the bowel with it. You can also have the patient carefully roll towards the side with the catheter to facilitate transfer of fluid over to the catheter.
  13. When you are done draining fluid, remove the catheter and massage the region where you catheter was vigorously between your fingers to break up any tract that may have formed from the catheter to avoid a persistent leak.
  14. If more than 4-5 L of fluid is withdrawn or if patient has hypotension or renal failure, albumin infusion can be given, but its utility has not been proven. Generally, eplace every 2L of fluid removed with 50cc of 25% (25g/100cc) albumin. Alternatively you can give 8-10g albumin for every liter of ascitic fluid removed.
  15. Walk your samples of fluid to lab intake immediately following procedure. Do not send down via nurse or tube system

INTERPRETATION OF RESULTS: ASCITIC FLUID ANALYSIS

Routine tests should include cell count, differential, albumin and total protein concentration, culture if appropriate. Optional tests of less value include glucose, LDH, gram stain, amylase.

If PMN count > 250/mm3, antibiotics should be used for possible SBP. Cefotaxime, a third-generation cephalosporin, has been shown to be superior to ampicillin plus tobramycin in a controlled trial [89]. Cefotaxime or a similar third-generation cephalosporin appears to be the treatment of choice for suspected SBP; it covers 95 percent of the flora including the 3 most common isolates:Escherichia coli, Klebsiella pneumoniae, and pneumococci [89]. Dosing of cefotaxime 2 g intravenously every 8 hours has been shown to result in excellent ascitic fluid levels (20-fold killing power after 1 dose) [90].

Intravenous Albumin Infusion in Addition to Cefotaxime a€” One controlled trial randomized patients with SBP to receive cefotaxime alone versus cefotaxime plus 1.5 g albumin per kg body weight within 6 hours of enrollment and 1.0 g/kg on day 3 [93]. A decrease in mortality from 29 percent to 10 percent was reported [93]. This is the lowest hospitalization mortality ever reported in a randomized trial of SBP [94]. Improving control of a complication of advanced cirrhosis is commonly reported; however, dramatically improving survival is seldom shown. This study warrants confirmation. While confirmation is awaited, it is reasonable to give albumin in this dose in this setting.

Bloody ascitic fluid may be from a traumatic tap; in this case the fluid is often streaked, and may clot.

Diffusely bloody fluid occurs with trauma, rarely TB, occasionally peritoneal carcinomatosis, and may be from portal hypertension due to rupture of lymphatics.

The serum-ascites albumin gradient should be calculated by measuring ascitic fluid and serum albumin.

 

References

89. Felisart, J, Rimola, A, Arroyo, V, et al. Randomized comparative study of efficacy and nephrotoxicity of ampicillin plus tobramycin versus cefotaxime in cirrhotics with severe infections. Hepatology 1985; 5:457.

90. Runyon, BA, Akriviadis, EA, Sattler, FR, Cohen, J. Ascitic fluid and serum cefotaxime and desacetyl cefotaxime levels in patients treated for bacterial peritonitis. Dig Dis Sci 1991; 36:1782.

91. Runyon, BA, McHutchison, JG, Antillon, MR, et al. Short-course vs long-course antibiotic treatment of spontaneous bacterial peritonitis:a randomized controlled trial of 100 patients. Gastroenterology 1991; 100:1737.

92. Navasa, M, Follo, A, Llovet, JM, et al. Randomized, comparative study of oral ofloxacin versus intravenous cefotaxime in spontaneous bacterial peritonitis. Gastroenterology 1996; 111:1011.

93. Sort, P, Navasa, M, Arroyo, V, et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med 1999; 341:403.

94. Runyon, BA. Albumin infusion for spontaneous bacterial peritonitis. Lancet 1999; 354:1838.