INTRODUCTION:

Paracentesis (from Greek κεντάω, "to pierce") is a form of body fluid sampling procedure,

generally referring to peritoneocentesis (also called laparocentesis or abdominal paracentesis)
in which the peritoneal cavity is punctured by a needle to sample peritoneal fluid.[1][2]
The procedure is used to remove fluid from the peritoneal cavity, particularly if this cannot be
achieved with medication. The most common indication is ascites that has developed in
people with cirrhosis
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/mm 3 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) 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

DIFINITION:

1
Paracentesis is also called abdominal tap, is a medical procedure in which a needle or catheter
is inserted into the peritoneal cavity (the area between the belly wall and the spine) to obtain
ascitic fluid for diagnostic or therapeutic purposes 1). Paracentesis procedure may be done in a
health care provider’s office, treatment room, or hospital. Ascitic fluid may be used to help
determine the cause of ascites, as well as to evaluate for infection or presence of cancer.
Ascites is the build-up of fluid in the space between the lining of the abdomen and abdominal
organs.

TYPES:-
Diagnostic: small quantity of fluid is removed for testing.
Therapeutic: >5 litres of fluid is removed to reduce intra-abdominal pressure and
relieve the associated symptoms like dyspnoea, abdominal pain and early satiety.
INDICATIONS

It is used for a number of reasons:

 to relieve abdominal pressure from ascites
 to diagnose spontaneous bacterial peritonitis and other infections (e.g. abdominal TB)
 to diagnose metastatic cancer
 to diagnose blood in peritoneal space in trauma
 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

CONTRAINDICATIONS
Mild hematologic abnormalities do not increase the risk of bleeding. The risk of bleeding
may be increased if:[8]

 prothrombin time > 21 seconds

 international normalized ratio > 1.6
 platelet count < 50,000 per cubic millimeter.
Absolute contraindication is acute abdomen that requires surgery.
Relative contraindications are:

 Pregnancy
 Distended urinary bladder
 Abdominal wall cellulitis
 Distended bowel
 Intra-abdominal adhesions

CONTRAINDICATIONS OF ABDOMINAL PARACENTESIS:

2
 1. Acute abdomen requiring immediate surgery (absolute contraindication)
2. Severe thrombocytopenia (platelet count <20 × 103/μL)
3. Coagulopathy (international normalized ratio [INR] >2.0)
4. In patients without clinical evidence of active bleeding, routine labs such as
prothrombin time (PT), activated partial thromboplastin time (aPTT), and platelet
counts may not be needed prior to the procedure.
5. Severe bowel distention (use extra caution)
6. Multiple previous abdominal operations
7. Pregnancy (absolute to midline procedure)
8. Distended bladder that cannot be emptied with a Foley catheter (relative
contraindication)
9. Obvious infection at the intended site of insertion (relative contraindication)
10. Severe hypoproteinemia (relative contraindication)
11. Intra-abdominal adhesions

TYPES OF PARACENTHESIS
 Diagnostic paracentesis — A small amount of fluid is taken and sent to the laboratory
for testing.
 Large volume paracentesis — Several liters may be removed to relieve abdominal
pain and fluid buildup.

PARACENTESIS PROCEDURE

Figure: Abdominal Paracentesis

FOR ASCITIES
The procedure is often performed in a doctor's office or an outpatient clinic. In an expert's
hands it is usually very safe, although there is a small risk of infection, excessive bleeding or
perforating a loop of bowel. These last two risks can be minimized greatly with the use of
ultrasound guidance.
The patient is requested to urinate before the procedure; alternately, a Foley catheter is used
to empty the bladder. The patient is positioned in the bed with the head elevated at 45-60
degrees to allow fluid to accumulate in lower abdomen. After cleaning the side of the

3
abdomen with an antiseptic solution, the physician numbs a small area of skin and inserts a
large-bore needle with a plastic sheath 2 to 5 cm (1 to 2 in) in length to reach the peritoneal
(ascitic) fluid. The needle is removed, leaving the plastic sheath to allow drainage of the
fluid. The fluid is drained by gravity, a syringe or by connection to a vacuum bottle. Several
litres of fluid may be drained during the procedure; however, if more than two litres are to be
drained it will usually be done over the course of several treatments. After the desired level of
drainage is complete, the plastic sheath is removed and the puncture site bandaged. The
plastic sheath can be left in place with a flow control valve and protective dressing if further
treatments are expected to be necessary.
If fluid drainage in cirrhotic ascites is more than 5 litres, patients may
receive intravenous serum albumin (25% albumin, 8g/L) to prevent hypotension (low blood
pressure). There has been debate as to whether albumin administration confers benefit, but
recent reviews report that it can reduce mortality after large volume paracentesis
significantly.
The procedure generally is not painful and does not require sedation. The patient is usually
discharged within several hours following post-procedure observation provided that blood
pressure is otherwise normal and the patient experiences no dizziness.

FOR FLUID ANALYSIS

The serum-ascites albumin gradient can help determine the cause of the ascites.[3]
The ascitic white blood cell count can help determine if the ascites is infected. A count of 250
WBC per ml or higher is considered diagnostic for spontaneous bacterial peritonitis. Cultures
of the fluid can be taken, but the yield is approximately 40% (72-90% if blood culture bottles
are used).

How to prepare for paracentesis

Let your healthcare provider know if you:

Have any allergies to medicines or numbing medicine

Are taking any medicines (including herbal remedies)
Have any bleeding problems
Might be pregnant
Paracentesis equipment includes the following:
1. Antiseptic swab sticks
2. Fenestrated drape
3. Lidocaine 1%, 5-mL ampule
4. Syringe, 10 mL
5. Injection needles, 22-gauge (two)
6. Injection needle, 25-gauge
7. Scalpel, No. 11 blade

4
 8. Catheter, 8 French, over 18-gauge × 7.5-in. needle with three-way stopcock, self-
sealing valve, and a 5-mL Luer-Lok syringe
9. Syringe, 60 mL
10. Introducer needle, 20-gauge
11. Tubing set with roller clamp
12. Drainage bag or vacuum container
13. Specimen vials or collection bottles (three)
14. Gauze, 4 × 4 in.
15. Adhesive dressing
Instruct to empty your bladder before starting the paracentesis procedure, either through
voluntary emptying on the part of the patient or through the use of a Foley catheter.

A. DIAGNOSTIC:
1.5 Inch, 22 Gauge needle
For Obese :3.5 Inch, 22 Gauge spinal needle
B. THERAPEUTIC:
15/ 16 Gauge needle to speed up the removal.
KIMBERLY – CLARK QUICK TAP PARACENTESIS TRAY CONTAINS
CADWELL NEEDLE which has a sharp inner trocar & blunt outer metal cannula
with side holes to permit withdrawal of fluid if end hole is occluded by bowel/
Omentum
C. POSITION OF THE PATIENT: Mostly Supine Head may be elevated Knee elbow
position for removal of minimal fluid in dependent area
D. SITE: Lt lower Quadrant (Dullness on percussion) 3cm medial & 2cm above the anterior
supra Iliac spine Not near umbilicus because of presence of collateral vessels Surgical
scars & visible veins should be avoided.
E. ABDOMINAL WALL ON LEFT: On the left Abdominal wall is thinner. Pool of fluid
is more. Patient can be rolled easily to left for drainage. WHY NOT RIGHT???
Appedicectomy scar, caecum filled with gas in pts taking lactulose. Care must be taken
not to injure inferior epigastic artery which bleeds massively & which is located near
pubic tubercle
F.

PARACENTESIS POSITION

5
Figure: Paracentesis Position

The preferred site for the procedure is in either lower quadrant of the abdomen lateral to the
rectus sheath. Paracentesis is done in a lateral decubitus or supine position.

 Placing the patient in the lateral decubitus position can aid in identifying fluid

pockets in patients with mild ascites (lower fluid volumes), with the skin entry site
near the gurney. The lateral decubitus position is advantageous because air-filled
loops of bowel tend to float in a distended abdominal cavity.
 Patients with severe ascites can be positioned supine.

The two recommended areas of abdominal wall entry for paracentesis are as follow:

 2 cm to 5 cm superior and medial to the anterior superior iliac spines on either side,
lateral to rectus abdominis muscle
 The puncture site will be cleaned and shaved, if necessary. You then receive a local
numbing medicine. The ascites fluid level is percussed, and a needle is inserted either
in the midline or lateral lower quadrant (2 cm to 5 cm superomedial to anterior
superior iliac spine). The paracentesis needle is inserted 1 to 2 inches (2.5 to 5 cm)
into the abdomen. Sometimes, a small cut is made to help insert the needle. The fluid
is pulled out into a syringe. The needle is removed. A dressing is placed on the
puncture site. If a cut was made, one or two stitches may be used to close it.

 This positioning avoids puncture of the inferior epigastric arteries

 Avoid visible superficial veins and surgical scars.
 The needle is inserted at a 45-degree angle or with a z-tracking technique to reduce
the risk of developing an ascites fluid leak.
 After proper antiseptic preparation and local anesthesia, a diagnostic paracentesis tap
can be performed with a 10- to 20-mL syringe and an 18-gauge needle.
6
  After proper antiseptic preparation and local anesthesia, a therapeutic paracentesis tap
can be performed with an intravenous (IV) catheter over the needle connected to
drainage tubing.
  Recommend the routine use of ultrasonography to verify the presence of a fluid
pocket under the selected entry site in order to increase the rate of success.
 The use of ultrasonography also helps the practitioner avoid a distended urinary
bladder or small bowel adhesions below the selected entry point. To minimize
complications, avoid areas of prominent veins (caput medusae), infected skin, or scar
tissue.

What abnormal results mean

An exam of abdominal fluid (ascitic fluid) may show:
 Cancer that has spread to the abdominal cavity (most often cancer of the ovaries)
 Cirrhosis of the liver
 Damaged bowel
 Heart disease
 Infection
 Kidney disease
 Pancreatic disease

THE PROCEDURE:
1. 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. 
2. 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. 

7
STEP 2
STEP

3. Step 3: Prep the skin with povidone-iodine or chlorhexidine solution, and allow it to dry
while applying sterile gloves and a mask
Pearl: Prep a wide area so that an undraped area is not inadvertently exposed
if the drape slides a little.
4. Step 4:Center the sterile drape about one third of the distance from the umbilicus to the
anterior iliac crest. 

8
 STEP 4

5. Step 5: 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 anaesthetic. 
6. Step 6: Insert the catheter/introducer through the skin. The non-dominant 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

7. 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. 
8. 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.

9
 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
9. 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

Possible complications of paracentesis procedure include:

 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
 Postparacentesis hypotension
 Dilutional hyponatremia
 Hepatorenal syndrome
 Persistent leakage of ascitic fluid at the needle insertion site. This can often be
addressed with a single skin suture.
 Abdominal wall hematoma
 Wound infection
 Perforation of surrounding vessels or viscera (extremely rare)

10
  Hypotension after large volume fluid removal (more than 5 liters to 6 liters). Albumin
is often administered after removal of more than 5 L of fluid to prevent this
complication.
 Failed attempt to collect peritoneal fluid
 Spontaneous hemoperitoneum – This rare complication is due to mesenteric variceal
bleeding after removal of a large amount of ascitic fluid (>4 L).
 Hollow viscus perforation (small or large bowel, stomach, bladder)
 Catheter laceration and loss in abdominal cavity
 Laceration of major blood vessel (aorta, mesenteric artery, iliac artery)
 Post paracentesis hypotension
 Dilutional hyponatremia
 Hepatorenal syndrome

POSTPROCEDURE INSTRUCTIONS
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. Lastly, the patient should be advised to clean the area with
warm soap and water and pat the area dry. 

CONCLUSION:

Normally, the abdominal cavity contains only a small amount of fluid. In certain
conditions, large amounts of fluid can build up in this space. Paracentesis can help diagnose
the cause of fluid buildup (ascites) or the presence of an infection. Paracentesis may also be
done to remove a large amount of fluid to reduce belly pain.

11
 BIBLIOGRAPHY

1. Kozier and Erb`s Fundamentals of nursing, concepts, process and practice, 8th edition,
Dorling Kindersley (India) pvt. Ltd. P-324-366
2. https://en.wikipedia.org/wiki/Paracentesis
3. https://medical-dictionary.thefreedictionary.com/abdominal+paracentesis
4. https://healthjade.com/paracentesis/
5. https://5minuteconsult.com/collectioncontent/30-156350/procedures/abdominal-
paracentesis
6. https://www.slideshare.net/AnveshNarime/abdominal-paracentesis-40281843
7. https://www.slideshare.net/girmawimedicine/abdominal-paracentesis-27124913

12
 COLLEGE OF NURSING
MEDICAL DIRECTORATE, LAMPHELPAT
SUBJECT: ADVANCE NURSING PRACTICE

PROCEDURE
ON
ABDOMINAL PARACENTESIS

SUBMITTED TO:
Mrs. A. Ibeyaima Devi
Associate Professor
HOD, Foundations of Nursing
College of nursing
Medical directorate
Lamphelpat

SUBMITTED BY:
Esther Mansuankim
1st Year M.Sc (N)
Roll No.- 2 (Two)
Specialty: Obstetrics &
Gynaecological Nursing
SUBMITTED ON: 02/03/2020 College of nursing
13
Medical Directorate
14