Oxford Medical Education

Ascitic tap (paracentesis)

oxfordmedicaleducation.com/clinical-skills/procedures/paracentesis/

November 16,
2014

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Ideally all ascitic interventions should be ultrasound guided
Indications for ascitic tap (paracentesis)
To aid diagnosis of the cause of ascites or in the diagnosis or exclusion of
SBP
A diagnostic paracentesis should be performed in all patients with
new onset grade 2 or 3 ascites, and in all patients hospitalized for
worsening of ascites or any complication of cirrhosis

Grade Definition Treatment

of
ascites

1 Mild ascites only detectable by No treatment

ultrasound

2 Moderate ascites evident by Restriction of sodium and

moderate symmetrical distension of diuretics
abdomen

3 Large ascites with marked abdominal Large volume paracentesis

distension followed by treatment as for
(2)

Equipment required for ascitic tap (paracentesis)

Ultrasound (ideally)
Dressing trolley & sharps bin
Sterile field
Sterile dressing pack
Sterile gloves
2% Chlorhexadine swabs
Analgesia
10mls of 1% or 2% Lidocaine
Orange (25G) needle (x1)
Green (19G) needle (x1)
10ml Syringe (x1)
20ml Syringe (x1)
with green (19G) needle (x1)
Specimen containers
Blood culture bottles
Dressing

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Contraindications to ascitic tap (paracentesis)
Overlying infection
Chose another site
Cautions – but not contraindications
Coagulopathy (INR>2.0)
Attempt to correct INR to <1.5 if possible.
Platelets<50
Thrombocytopenia and coagulopathy is often present in liver
disease and though it is a caution, it not a contraindication to
paracentesis or drainage
The incidence of clinically significant bleeding is low; routine FFP
or platelets is not indicated
Pregnancy
Organomegaly
Obstruction/ileus
Distended bladder
Abdominal adhesions

Pre-procedure
Consent patient and explain procedure
Consent for infection, bleeding, pain, failure, damage to surrounding
structures (especially bowel perforation – rare), leakage
Lie patient flat and examine clinically to confirm ascites
Ultrasound area for insertion
Define landmarks
Aim for 1/3 to ½ of the way between the anterior superior iliac spine
and the umbilicus avoiding vessels and scars

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Procedure for ascitic tap (paracentesis)
Position the patient supine in the bed with their head resting on a pillow.
Select an appropriate point on the abdominal wall in the right or left lower
quadrant, lateral to the rectus sheath. If a suitable site cannot be found with
palpation and percussion consider using ultrasound to mark a spot.
Clean the site and surrounding area with 2% Chlorhexadine and apply a
sterile drape.
Anaesthetise the skin with Lidocaine using the orange needle.
Anaesthetise deeper tissues using the green needle, aspirating as you
insert the needle to ensure you are not in a vessel before infiltrating with
lidocaine. Use a maximum of 10mls of Lidocaine.
Take a clean green needle and 20ml syringe and insert through the skin
advancing and aspirating until fluid is withdrawn
Aspirate 20ml
Remove needle and apply sterile dressing

Watch Video At: https://youtu.be/_r7MaXw1CFw

NEJM video on paracentesis

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Samples in paracentesis
Microbiology
Microscopy, culture & sensitivities (be explicit if yeast or
mycobacterium suspected)
Culture in blood culture bottles inoculated at the bedside
Haematology
Automated WCC count (send EDTA sample)
Biochemistry
Albumin, Protein, LDH, Glucose
Remember to send a serum albumin, LDH and glucose at the same
time (or at least from the same day).
Special tests: Fluid amylase, Triglycerides, Bilirubin
Cytology
Sent the largest sample
Samples can also be sent for immunology (RF, ANA) and TB culture if
clinically indicated

In the event of failure

Stop procedure
Seek senior help
Consider further imaging or aspiration in radiology

Top Tips for ascitic tap (paracentesis)

Always send the most fluid to cytology, especially if malignancy is
suspected. The more fluid sent, the higher the diagnostic yield.
Never dispose of unused fluid, put it in an extra pot and add to the cytology
sample.
If you want to gain a larger sample use a 50ml syringe to aspirate fluid
In patients with a thick abdominal wall a spinal needle can be used to
infiltrate anaesthetic and check position.
If you aspirate blood when infiltrating an anaesthetic; stop, withdraw your
needle, change position by 1-2cm and try again.

Click here for medical student OSCE and PACES examples

of ascitic fluid analysis

Common ascitic flid interpretation exam questions for medical students,

finals, OSCEs and MRCP PACES
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Click here to download free teaching notes on doing an
ascitic tap (paracentesis): Procedures – Ascitic tap

Perfect revision for medical students, finals, OSCEs and MRCP PACES

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