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ASSIGNMENT ON ABDOMINAL
PARACENTESIS

SUBMITTED TO, SUBMITTED BY,

PROF MRS REGI PHILIP AXSA ALEX
HOD OF MSN DEPT 1ST YEAR MSc NURSING
SJCON,ANCHAL SUBMITTED ON;10/4/2020 SJCON ,ANCHAL
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INTRODUCTION

Abdominal paracentesis is a safe and effective diagnostic and therapeutic procedure used in the
evaluation of a variety of abdominal problems, including ascites, abdominal injury, acute abdomen,
and peritonitis. Ascites may be recognized on physical examination as abdominal distention and the
presence of a fluid wave. Therapeutic paracentesis is employed to relieve respiratory difficulty due
to increased intra-abdominal pressure caused by ascites.

Midline and lateral approaches can be used for paracentesis, with the left-lateral technique more
commonly employed. The left-lateral approach avoids air-filled bowel that usually floats in the ascitic
fluid. The patient is placed in the supine position and slightly rotated to the side of the procedure to
further minimize the risk of perforation during paracentesis. Because the cecum is relatively fixed on
the right side, the left-lateral approach is most commonly used.

Most ascetic fluid reaccumulates rapidly. Some experts recommend that no more than 1.5 L of fluid
be removed in any single procedure. Patients with severe hypoproteinemia may lose additional
albumen into reaccumulations of ascites fluid and develop acute hypotension and heart failure.
Cancer patients with malignant effusions may also need repetitive therapeutic paracentesis.
Intravenous fluid and vascular volume support may be required in these patients if larger volumes
are removed.

After diagnostic paracentesis, fluid should be sent to the laboratory for Gram stain; culture; cytology;
protein, glucose, and lactate dehydrogenase levels; and blood cell count with a differential cell
count. A polymorphonuclear cell count of >500 cells/mm3 is highly suggestive of bacterial
peritonitis. An elevated peritoneal fluid amylase level or a level greater than the serum amylase level
is found in pancreatitis. Grossly bloody fluid in the abdomen (>100,000 red blood cells/mm3)
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indicates more severe trauma or perforation of an abdominal organ. The classic positive test for
hemoperitoneum is the inability to read newspaper type through the paracentesis lavage fluid.

EQUIPMENT
Disposable paracentesis/thoracentesis kits usually include the following: 
 Antiseptic swab sticks
 Fenestrated drape
 Lidocaine 1%, 5-mL ampule
 Syringe, 10 mL
 2-inch-long injection needle
 No. 11 blade scalpel
 14-gauge catheter over 17-gauge × 6-inch needle with three-way stopcock or one-way
valve, self-sealing valve, and a 5-mL Luer Lock syringe
 Syringe, 60 mL
 Tubing set with roller clamp
 Drainage bag or vacuum container
 Specimen vials or collection bottles (3)
 Gauze, 4 inch × 4 inch
 Adhesive dressing
INDICATIONS
 Evaluation of ascites fluid to help determine etiology, to differentiate transudate
versus exudate, to detect the presence of cancerous cells, or to address other
considerations
 Evaluation of blunt or penetrating abdominal injury
 Relief of respiratory distress due to increased intra-abdominal pressure
 Evaluation of acute abdomen
 Evaluation of acute or spontaneous peritonitis
 Evaluation of acute pancreatitis
CONTRAINDICATION
The Contraindication
-Absolute
-Relative
Absolute Contraindication
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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.
11. Primary fibrinolysis (which should be suspected in 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 the paracentesis should be modified in patients with surgical scars so that
the needle 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. Bowel 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 Contraindication
1) Severe thrombocytopenia platelet count < 20 X 103/μL and coagulopathy (international
normalized ratio [INR] >2.0)
2) Pregnancy
3) Distended urinary bladder
4) Abdominal wall cellulitis
5) Distended bowel
6) Intra-abdominal adhesions
• Patients with an INR greater 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/μL should receive an infusion of platelets
prior to performing the procedure.
• In patients without clinical evidence of active bleeding, routine laboratory tests such as
prothrombin time (PT), activated partial thromboplastin time (aPTT), and platelet counts may
not be needed prior to the procedure.Inthese patients,pretreatment with FFP, platelets, or both
before the paracentesis is also probably not needed
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PREPARATION
• No need of preparation
PATIENT POSITION
 Usually performed with patient supine position
 Rarely patient can 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 airfilled loops of bowel tend to
float in a distended abdominal cavity.
NEEDLE ENTRY SITE
• The two recommended areas of abdominal wall entry for paracentesis are as follows.
- 2 cm below the umbilicus in the midline (through the lineaalba)
-5 cm superior and medial to the anterior superior iliac spines on either side(in update 3cm)
• 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. However, the recanalized umbilical vein may
be present caudal to the umbilicus in the midline, an area that should be avoided.
NEEDLE ENTRY SITE TO AVOID
 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 sheath. This artery can
be 3 mm in diameter and can bleed massively if punctured with a large- caliber needle. Thus,
this site should be specifically avoided.
 areas near surgical scars should be avoided.
 Visible veins should also be avoided.
PROCEDURE
Step 1
The anatomy of the abdominal wall is shown. The insertion sites may be midline or through
the oblique transversus muscle, which is lateral to the thicker rectus abdominus muscles. 
Step 2
Empty the patient’s bladder either voluntarily or with a Foley catheter. Place the patient in the
horizontal supine position, and tilt the patient slightly to the side of the collection (usually the
left lower quadrant). Slightly rotate the hip down on the table on the side of needle insertion
to make that quadrant of the abdomen more dependent. The insertion sites are shown. 
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STEP 2

Step 3
Prep the skin with povidone-iodine or chlorhexidine solution, and allow it to dry while
applying sterile gloves and a mask.  Prep a wide area so that an undraped area is not
inadvertently exposed if the drape slides a little.

Step 4
Center the sterile drape about one third of the distance from the umbilicus to the anterior iliac
crest. 
STEP 4

Step 5
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Infiltrate the skin and subcutaneous tissues with a 1% solution

of lidocaine with epinephrine. A 2-inch needle is then inserted perpendicular to the skin to
infiltrate the deeper tissues and peritoneum with anesthetic. 
Step 6
Insert the catheter/introducer through the skin. The nondominant hand then stretches the skin
to one side of the puncture site, and the needle is further inserted to create a Z tract. 
STEP 6

Step 7
Advance the catheter until a “pop” is felt and the catheter penetrates the peritoneum. Release
the pressure on the skin after the introducer enters the peritoneum. Advance the catheter into
the abdominal cavity. 
Step 8
Remove the introducer, and attach the syringe. Draw the fluid into the syringe. If no fluid
returns, rotate, slightly withdraw, or advance the catheter until fluid is obtained. If still no
fluid returns, abort the procedure, and try an alternative site or method. Ascites fluid may be
removed by attaching a three-way stopcock or one-way valve, a 60-cc syringe to one arm,
and drainage tubing and bag to the other arm. If lavage is desired, such as for detecting
hemoperitoneum after trauma, connect intravenous tubing to the three-way stopcock. Remove
excess fluid and then infuse 700 to 1,000 mL of Ringer lactate or normal saline into the
abdominal cavity. Gently roll the patient from side to side. Then, remove the fluid as
described above or using a trap-suction arrangement. 
STEP 8
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Step 9
After the procedure, gently remove the catheter, and apply direct pressure to the wound.
Observe the characteristics of the fluid, and send it for the appropriate studies. If the insertion
site is still leaking fluid after 5 minutes of direct pressure, suture the site with a vertical
mattress suture. Apply a pressure dressing. 
COMPLICATIONS
 Abdominal radiographs should be obtained before paracentesis, because air may be
introduced during the procedure and may interfere with interpretation.
 Perforation of bladder and stomach (emptied prior to the procedure to decrease the
risk)
 Bowel perforation
 Laceration of a major blood vessel
 Loss of catheter or guide wire in the peritoneal cavity
 Abdominal wall hematomas
 Pneumoperitoneum
 Bleeding
 Perforation of the pregnant uterus
 Infection
 Persistent leak from the puncture site
 Post paracentesis hypotension
 Dilutional hyponatremia
 Hepatorenal syndrome
HEALTH EDUCATION
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 The patient should be instructed to monitor the bleeding of the area and return if any
abnormal bleeding is noted.
 The patient should also be educated to call with questions or concerns regarding pain,
numbness, or discomfort in the area.
 The patient should also monitor for evidence of infection.
 The patient should be advised to clean the area with warm soap and water and pat the
area dry. 
BIBLIOGRAPHY
1 Cappell MS, Shetty V. A multicenter, case-controlled study of the clinical presentation and
etiology of ascites and of the safety and clinical efficacy of diagnostic abdominal paracentesis
in HIV seropositive patients. Am J Gastroenterol .  1994;89:2172–217
2 Guarner C, Soriano G. Spontaneous bacterial peritonitis. Semin Liver Dis .  1997;17:203–
217. 
3 Gupta S, Talwar S, Sharma RK, et al. Blunt trauma abdomen: a study of 63 cases. Indian J
Med Sci  .  1996;50:272–276. 
4 Halpern NA, McElhinney AJ, Greenstein RJ. Postoperative sepsis: reexplore or observe?
Accurate indication from diagnostic abdominal paracentesis. Crit Care Med .  1991;19:882–
886.
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