By A.B.

Sani KKB SON KT

PARACENTESIS
By A.B.Sani KKB SON KT
By A.B.Sani KKB SON KT

INTRODUCTION/ OVERVIEW

DESCRIPTION

• Performed to obtain samples of ascitic fluid for diagnostic and therapeutic purposes by
insertion of a trocar and cannula through the abdominal wall

• May be performed using image guidance

• In four-quadrant tap, aspirates fluid from each quadrant of the abdomen to verify
abdominal trauma and the need for surgery

• In peritoneal fluid analysis, assesses gross appearance, red blood cell (RBC) and white
blood cell (WBC) counts, cytologic studies, and microbiological studies for bacteria and
fungi and determines protein, glucose, amylase, ammonia, and alkaline phosphatase
levels

DEFINITION

Abdominal paracentesis is the act of puncturing into a peritoneal cavity for the purpose of
draining fluid or aspirating fluid.

Or

Abdominal paracentesis is a bed side clinical procedure in which needle is inserted into
peritoneal cavity and ascitic fluid is removed.

TYPES

1) Diagnostic: small quantity of fluid is removed for testing.

2) Therapeutic: >5 litres of fluid is removed to reduce intra-abdominal pressure and relieve the
associated symptoms like dyspnoea, abdominal pain and early satiety.

PURPOSE

 To determine the cause of ascites

 To detect abdominal trauma

 To remove accumulated ascitic fluid

INDICATIONS FOR PARACENTESIS

 Testing of ascitic fluid.

 For evaluation of patient with ascitis who has signs of clinical deterioration like
fever, abdominal pain, hepatic encephalopathy, decreased renal function and
metabolic acidosis.
 Paracentesis can identify unexpected diagnosis such as chylous, haemorrhagic or
esinophilic ascites useful to know etiology and antibiotic susceptibility.
By A.B.Sani KKB SON KT

 New onset ascites with unknown etiology

 Respiratory compromise

 Unexplained leukocytosis, acidemia, renal failure

CONTRAINDICATIONS

 Must be careful if minimal fluid visualized on Ultra Sound

 In peritoneal carcinomatosis, do not do this procedure yourself

• Gut gets tethered to the anterior abdominal wall and can’t move away from your
needle; you can perforate it.

 Patient with Deciminated Intavascular Coagulation

 Massive ileus with bowel distension.
 Near the surgical scar bcoz scars are asso. With tethering of bowel to abd.wall n will
cause bowel perforation.
 Infections

REQUIREMENT ON A TRAY

• Gallipot, swabs, paper towel, forceps, trocar and cannula or dialysis catheter and
introducer, scissors, scalpel handle and blade in a sterile tray with cover.

• Syringe and Needle

• Needle holder, needle and silk

• Gloves, drainage tubing and bag

• Specimen bottles, laboratory forms, antiseptic Adhesive plaster

• Local anaesthesia

• Many tailed binder Masks

CHOICE OF NEEDLE

 Diagnostic: 1.5 Inch, 22 Gauge needle

 For Obese: 3.5 Inch, 22 Gauge spinal needle
 Therapeutic: 15/ 16 Gauge needle to speed up the removal.

PROCEDURE

PREPARATION

 Make sure that the practitioner has had the patient sign an appropriate consent form.

 Note and report allergies.

By A.B.Sani KKB SON KT

 No dietary restrictions are required.

TEACHING POINTS

 If the patient has severe ascites, inform him that the procedure will relieve his discomfort
and allow him to breathe easier.

 Explain who will perform the test and where it'll be done.

 Inform the patient that he'll receive a local anesthetic.

 Explain that a blood sample may be taken for analysis.

 Tell the patient that he doesn't have to restrict his diet.

 Tell the patient that the test takes 45 to 60 minutes.

DURING

 Perform hand hygiene.

 Confirm the patient's identity using at least two patient identifiers.

 Obtain baseline vital signs, weight, and abdominal girth measurement.

 Assist the patient into the supine position.

 If the patient can't tolerate being supine, Assist patient into fowler's (sitting) position with
many tailed binder in position behind patient

 The practitioner prepares and drapes the puncture site using sterile technique.

 Immediately before starting the procedure, the procedure team takes a time-out to verify
the correct patient, procedure, and site.

 Local anesthetic is injected.

 Ask patient to empty bladder

 Nurse - puts on mask, washes hands, open pack and gloves

 Doctor puts on mask, washes hands puts on gloves and opens inner pack

 Nurse - pours solution

 Doctor draws up and injects same and then inserts tr and cannula into position and
connect drainage tube and bag.

 Positioning

• Mostly Supine
• Head may be elevated
By A.B.Sani KKB SON KT

• Knee elbow position for removal of minimal fluid in dependent area

 Site

 Nurse - applies many tailed binder. This should be tightened at intervals as f1uid drains
out.

 Measure volume of fluid

 Doctor may specify volume of fluids to be drained in a given time.

 Observe patient for signs of shock.

 Maintain intake and output chart

 After the procedure, make patient comfortable and record procedure appropriately and
report to the charge Nurse

POSTPROCEDURE CARE

• Give I.V. infusions and albumin.

• Monitor vital signs and intake and output.

• Observe the puncture site and drainage for bleeding and infection.

• Obtain the patient's daily weight and daily abdominal girth measurement.

• Observe the patient for hematuria, which may indicate bladder trauma.

• Monitor serum electrolyte (especially sodium) and protein levels.

By A.B.Sani KKB SON KT

COMPLICATIONS

• Bleeding, hemorrhage

• Infection

• Bladder trauma

• Shock

• Perforated intestine

• Inferior epigastric artery puncture

• Anterior cecal wall hematoma

• Iliac vein rupture

INTERPRETATING RESULTS

NORMAL RESULTS

• Fluid is odorless and clear to pale yellow.

ABNORMAL RESULTS

• Milk-colored fluid may indicate chylous ascites.

• Bloody fluid may indicate a tumor, hemorrhagic pancreatitis, or perforated intestine or

duodenal ulcer.

• Cloudy or turbid fluid may indicate peritonitis or an infectious process.

• RBC count above 100/µL (SI, > 100/L) suggests neoplasm or tuberculosis. RBC count
above 100,000/µL (SI, > 100,000/L) suggests intra-abdominal trauma.

• WBC count above 300/µL with more than 25% neutrophils suggests spontaneous
bacterial peritonitis or cirrhosis.

• A high percentage of lymphocytes suggests tuberculous peritonitis or chylous ascites.

• A protein ascitic fluid-serum ratio of 0.5 or greater may suggest a malignancy or

tuberculous or pancreatic ascites.

• Protein levels rise above 3 g/dL (SI, > 3 g/L) in malignancy and above 4 g/dL (SI, > 4
g/L) in tuberculosis.

• Albumin gradient between ascitic fluid and serum greater than 1 g/dL (SI, > 1 g/L)
indicates chronic hepatic disease.

• Gram-positive cocci usually indicate primary peritonitis; gram-negative organisms

indicate secondary peritonitis.
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• Fungi may indicate histoplasmosis, candidiasis, or coccidioidomycosis.

SELECTED REFERENCES

Fischbach, F. T., & Fischbach, M. A. (2018). A manual of laboratory and diagnostic tests (10th
ed.).

Philadelphia, PA: Wolters Kluwer.

Phillips, M. M. (2017). “Peritoneal Fluid Analysis” [Online]. Accessed June 2019 via the Web at
https://www.nlm.nih.gov/medlineplus/ency/article/003626.htm

Runyon, B. A. Diagnostic and therapeutic abdominal paracentesis. (2018). In: UpToDate,

Chopra, S. (Ed).

Runyon, B. A. Evaluation of adults with ascites. (2019). In: UpToDate, Lindor, K. D. (Ed.).

Runyon, B. A. Spontaneous bacterial peritonitis in adults: Diagnosis. (2018). In: UpToDate,

Lindor, K. D. (Ed.).

Shlamovitz, G. Z. (2018). “Paracentesis” [Online]. Accessed June 2019 via the Web at
http://emedicine.medscape.com/article/80944-overview