Abdominal Paracentesis

KELLE UNIVERSTY COLLEGE OF HEALTH
ME
SCIENCE AYDER REFERRAL HOSPITAL
LECTURE ON ABDOMINAL PARACENTESI

PREPARED BY
GIRMAWI MEBRAHTOM
CII
24/ 1
/ 0
6E.C
AL PARACENTESIS
ABDOMIN
Abdomen Needle Ascites

Drain
Drainage container
Abdominal Paracentesis
prepared by
Girmawi.M CIL
CONTENT
→ Definition > Indication
Contraindication
►Technique > Complication
fter procedure
► Follow /A
cont
• Paracentesisis a p
rocedure in which a needle or
catheter
is inserted into the peritoneal cavity to obtain ascitic
fluid for diagnostic or therapeutic purposes.
paracentesis can be done f or
-diagnostic or -therapeutic purpose
• Diagnostic paracentesis refers to the removal of a

small quantity of f luid for t esting.
Cont
• Therapeutic paracentesis refers to the

removal of 5 liters or more of fluid To reduce and
relives
- intra-abdominal pressure -dyspnea, -abdominal pain,
and -early satiety.
INDICATION
→ 1-Diagnostic tap
is used for the following:
v-onset ascites: Fluid evaluation helps to
determine etiology,
differentiate transudate versus exudate,
detect the presence of c ancerous cells, or
address other considerations b) Suspected

spontaneous or secondary bacterial peritonitis
► 2-Therapeutic tap
is used for the following: a) Respiratory compromise
secondary to ascites b) Abdominal pain or pressure
secondary to ascites (including abdominal
compartment syndrome)
CONTRAINDICATION
► The Contraindication
-Absolute - Relative
Absolute C ontraindication
1. Patients with clinically apparent disseminated

intravascular coagulation and oozing from needle
sticks probably should not undergo paracentesis. This
occurs in <1/1000 patients with ascites in our
experience.
ich should be suspected in

1. Primary fibrinolysis (wh
patients with large, three-dimensional bruises) is
probably another contraindication. Paracentesis can be
performed once the bleeding risk is reduced with
treatment.
3. Paracentesis should not be performed in patients

with
a massive ileus with bowel distension unless the
procedure is image-guided to ensure that the bowel is
not entered.
4. The location of t he paracentesis should be modified

in patients with surgical scars so that the n
eedle is
inserted several centimeters away from the scar.
Surgical scars are associated with tethering of the
bowel to the abdominal wall, increasing the risk of
bowel perforation. B owel perforation by the
paracentesis needle occurs in approximately 6/1000
taps. Fortunately, it is generally well tolerated
5. an acute abdomen that requires surgery is an

absolute
contraindication..
Relative C
ontraindication
1) Severe thrombocytopenia platelet count < 20 X

103/uL and
coagulopathy (international normalized ratio (INR] >2.0)
2) Pregnancy 3) Distended u rinary bladder 4)
Abdominal wall cellulitis 5) Distended bowel 6)
Intra-abdominal adhesions
• Patients with an INR g
reater than 2.0 should receive
fresh
frozen plasma (FFP) prior to the procedure.
One strategy is to infuse one unit of fresh frozen

plasma before the procedure and then perform the
procedure while the second unit is infusing.
Patients with platelet count of less than 20 X 103/uL

should receive an i nfusion of platelets prior to
performing the procedure.
• In patients without clinical evidence of active bleeding,

routine
laboratory tests such a
s prothrombin time (PT),
activated partial thromboplastin time (aPTT), and
platelet counts may not b
e needed prior to the
procedure. Inthese patients, pretreatment with FFP,
platelets, or both before the paracentesis is also
probably not needed
Preparation
- Noned or no reparation
• No need of preparation
PATIENT P OSITION
> Usually performed with p

atient supine position
X-Plain
> Rarely patient c an be positioned lateral decubitus

This is used only 1-there is small amount of fluid and
2-The suspected diagnosis is crucial to the patient
outcome(eg,Tb peritonitis)
► The lateral decubitus position is advantageous
because air
filled loops of bowel tend to float in a distended
abdominal cavity.
ite
Needle Entry S
• The two recommended areas of abdominal wall

entry for paracentesis are as follows.
- 2 cm below the umbilicus in the midline (through the
linea alba)
-5 cm superior and m edial to the anterior superior iliac
spines on either side (in update 3cm)
Cont'd
• The midline approach is now seldom used since

most
paracenteses (about 90 percent) are therapeutic and
many patients are obese.
• In the past, the midline, cephalad from the umbilicus,
was frequently used as the site of needle entry
because of its relative avascularity. Howe ver, the
recanalized umbilical vein may be present caudal to the
umbilicus in the midline, an area that should be
avoided.
Needle E ntry S ite To Av oid
• The inferior epigastric artery traces from a point just

lateral to
the pubic tubercle (which is 2 to 3 cm lateral to the
symphysis pubis), cephalad within the rectus s heath.
This artery can be 3 m

m in diameter and can bleed
massively if punctured with a large- caliber needle.
Thus, this site should be s pecifically avoided.
areas near surgical scars should be avoided. V
isible
veins should also be a voided.
Equipment
paracentesis catheter
large syringe
evacuated containter
antiseptic
Antiseptic swab sticks Fenestrated drape Lidocaine 1%,
5-mL ampule Syringe, 10 mL Injection needles, 22
gauge (ga), 2 Injection needle, 25 ga Scalpel, no. 11
blade Catheter, 8F, over 18 ga!
7 1/2
" needle with 3-way stopcock, self-sealing valve,
and a 5-ml Luer-Lock s yringe Syringe, 6 0 mL
Introducer needle, 20 g a Tubing set with roller clamp
Drainage bag or vacuum container Specimen vials or
collection bottles, 3 G auze, 4! 4 inch Adhesive dressing
lidocaine & syringe
sterile gauze
bandage specimen
tubes
high-pressure tubing
Technique
1 Explain the procedure, benefits, risks, complications,

and
alternative options to the patient or the patient's
representative. 2 Obtain s igned informed consent. 3
Empty the patient's bladder, either voluntarily or with a
Foley
catheter. 4 Position the patient and prepare the skin
around the entry site with
an antiseptic solution
X-Plain
Cont'd
5
Apply a sterile fenestrated drape to create a sterile field
6 Use the 5-mL syringe a

nd the 25-ga needle to raise a
small
lidocaine skin wheal around the skin entry site
Cont'd
©
Switch to the longer 20-ga needle and administer 4-5
mL of lidocaine along the catheter insertion tract (see
image below). Make sure to anesthetize all the way
down to the peritoneum. The authors recommend
alternating injection and intermittent aspiration down
the tract until ascitic fluid is noticed in the syringe. Note
the depth at which the peritoneum i s entered. In obese
patients, reaching the peritoneum may involve passing
through a significant amount of adipose tissue.
Bibliomed hz
Cont'd
8
Use the No. 11 scalpel blade to make a s mall nick in
the skin to allow an easier catheter passage
8
Insert the needle directly perpendicular to the selected
skin entry point. Slow insertion in increments of 5 mm
is preferred to minimize the risk of inadvertent vascular
entry or puncture of the small bowel.
-Epidermis
Epiduri
pull down
Insert needle
Peritoneum
Release
Cont'd
10
Continuously apply negative pressure to the syringe as
the needle is advanced. Upon entry to the p eritoneal
cavity, loss of resistance is felt and ascitic fluid can be
seen filling the syringe . At this point, advance t he
device 2-5 mm into the peritoneal cavity to prevent
misplacement during catheter advancement. In
general, avoid advancing the needle deeper than the
safety mark that is present on most commercially
available catheters or deeper than 1 cm beyond the
depth at which ascitic fluid was noticed in the lidocaine
syringe.
Cont'd
11 Use one hand to firmly anchor the needle and

syringe securely in
place to prevent the needle from entering further into
the peritoneal cavity
12
Use the other hand to hold the stopcock and catheter
and advance the catheter over the needle and into the
peritoneal cavity all t he way to the skin (see image and
video below). If any resistance is noticed, the c atheter
was probably misplaced into the subcutaneous tissue.
If this is the case, withdraw the device completely and
reattempt insertion. When withdrawing the device,
always remove the needle and catheter together as a
unit in order to prevent the bevel from cutting the
catheter
Cont'd
13 While holding the stopcock, pull the needle out.

The self-sealing valve
prevents fluid leak.
Attach the 60-mL syringe t o the 3-way stopcock and
aspirate to obtain ascitic f luid and distribute it to the
specimen vials (see images and video below). Use the
3-way valve, as needed, to control fluid flow and
prevent leakage when no syringe or tubing is attached.
Cont'd
14 Connect one end of the fluid collection tubing to the
stopcock and
the other end to a vacuum bottle or a drainage bag.
Cont'd
• The catheter can become occluded by a loop of bowel

or omentum.
If the flow stops, kink or clasp the tubing to avert loss of
suction, then break the seal and manipulate the
catheter slightly, t hen reconnect a nd see if flow
resumes. Rotating the catheter a bout the long axis can
sometimes reinstitute flow i n models with side ports.
Remove the catheter after the desired amount of ascitic

fluid has been drained (see image below). Apply firm
pressure to stop bleeding, if present. Place a bandage
over the skin puncture site.
Complication
• Failed attempt to collect peritoneal fluid

Persistent leak from the puncture site
• Wound infection
• Abdominal wall hematoma
Spontaneous hemoperitoneum: This rare complication
is due to mesenteric variceal bleeding after r emoval of
a large amount of ascitic
fluid (>4 L).
• Hollow viscous perforation (small or large bowel,
stomach, bladder)
• Catheter laceration and loss in abdominal cavity
• Laceration of major blood vessel (aorta, mesenteric
artery, iliac artery)
• Postparacentesis hypotension
• Dilutional hyponatremia
• Hepatorenal syndrome
K YOU
THAN

Abdominal Paracentesis

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​ ​KELLE ​UNIVERSTY ​COLLEGE ​OF ​HEALTH

LECTURE ON ​ABDOMINAL PARACENTESI

Abdomen ​Needle ​Ascites

→ ​Definition ​> ​Indication

►Technique ​> ​Complication

• ​Diagnostic paracentesis ​refers to ​the removal ​of ​a

• ​Therapeutic ​paracentesi​s ​refers ​to ​the

v​-​onset ​ascites: ​Fluid ​evaluation helps ​to

address ​other ​considerations ​b​) ​Suspected

1​. ​Patients with ​clinically ​apparent ​disseminated

​ ich ​should ​be ​suspected ​in

3​. ​Paracentesis ​should ​not ​be ​performed ​in ​patients

4​. ​The ​location ​of t​ he ​paracentesis ​should ​be ​modified

5​. ​a​n ​acute ​abdomen ​that ​requires ​surgery ​is ​an

1​) ​Severe ​thrombocytopenia ​platelet count ​< ​20 ​X

One ​strategy ​is ​to ​infuse ​one unit of ​fresh frozen

Patients ​with ​platelet ​c​o​unt ​of ​less than ​20 ​X 103​/​uL

• ​In ​patients ​without ​clinical ​evidence ​of ​active ​bleeding​,

> ​U​sually ​performed ​with p

> ​Rarely ​patie​n​t c​ an ​be ​positioned ​lateral ​decubitus

• ​The ​two ​recommended ​areas ​of ​abdominal ​wall

• ​The ​midline ​approach ​is ​now ​seldom ​used ​since

• ​The ​inferior ​epigastric ​artery ​traces ​from ​a ​point ​just

This ​artery ​can ​be ​3 m

1 ​E​xplain ​the ​procedure​, ​benefits​, ​risks​, ​complications​,

6 ​Use ​the ​5​-​mL ​syringe a

11 ​Use ​one ​hand ​to ​firmly ​anchor ​the ​needle ​and

1​3 ​While ​holding the ​stopcock​, ​pull the needle ​out​.

• ​The ​catheter ​can ​become ​occluded ​by ​a ​loop ​of ​bowel

Remove ​the ​catheter after ​the ​desired ​amount of ​ascitic

• ​Failed ​attempt ​to ​collect ​peritoneal ​fluid

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KELLE UNIVERSTY COLLEGE OF HEALTH

LECTURE ON ABDOMINAL PARACENTESI

Abdomen Needle Ascites

→ Definition > Indication

►Technique > Complication

• Diagnostic paracentesis refers to the removal of a

• Therapeutic paracentesis refers to the

v-onset ascites: Fluid evaluation helps to

address other considerations b) Suspected

1. Patients with clinically apparent disseminated

ich should be suspected in

3. Paracentesis should not be performed in patients

4. The location of t he paracentesis should be modified

5. an acute abdomen that requires surgery is an

1) Severe thrombocytopenia platelet count < 20 X

One strategy is to infuse one unit of fresh frozen

Patients with platelet count of less than 20 X 103/uL

• In patients without clinical evidence of active bleeding,

> Usually performed with p

> Rarely patient c an be positioned lateral decubitus

• The two recommended areas of abdominal wall

• The midline approach is now seldom used since

• The inferior epigastric artery traces from a point just

This artery can be 3 m

1 Explain the procedure, benefits, risks, complications,

6 Use the 5-mL syringe a

11 Use one hand to firmly anchor the needle and

13 While holding the stopcock, pull the needle out.

• The catheter can become occluded by a loop of bowel

Remove the catheter after the desired amount of ascitic

• Failed attempt to collect peritoneal fluid