CG0366

PROTOCOL FOR ABDOMINAL PARACENTESIS

Indications

Diagnostic tap:

 New-onset ascites of uncertain cause

 Suspected spontaneous bacterial peritonitis (SBP)

Therapeutic tap:

 Symptomatic diuretic resistant/intolerant ascites (Respiratory compromise or

abdominal pain/pressure)

Contraindications

Absolute:

 An acute abdomen (ask for surgical opinion if in doubt)

Cautions – but not contraindications:

1. An elevated INR or thrombocytopenia is not a contraindication to paracentesis.

Exceptions are patients with clinically apparent disseminated intravascular
coagulation or clinically apparent hyper fibrinolysis, who do require treatment to
decrease their risk of bleeding. Discuss with haematologist in such cases
2. Pregnancy
3. Organomegaly
4. Obstruction/ileus ( Use USS guided paracentesis to avoid bowel perforation)
5. Distended bladder
6. Abdominal adhesions
7. Infection of overlying skin. Choose another site

Potential complications

 Sepsis
 Perforation of a viscus or a vessel causing haemorrhage
 Intravascular volume depletion (hypotension) and renal impairment
 Exacerbation of hepatic encephalopathy
 Post-drainage fluid leak
Laboratory analysis of ascitic fluid

 White Cell count: Send 2 samples of ascitic fluid, one in an EDTA (purple top) bottle
and the other in a sterile (red/white top) container. Both samples should go in one
microbiology (green colour) form to microbiology lab in CAH. All ascitic fluid samples
are processed in CAH. Inform microbiology lab in CAH before sending sample.
Contact numbers are: 028 3861 2547 during working hours (08:00 AM to 05:00 PM);
078 0129 2773 during out of hours, weekends and bank holidays. An ascitic
neutrophil count >250 cells/mm³ (0.25×109/l) is diagnostic of SBP.

 Culture: (Blood culture bottles: 5ml of ascitic fluid in each bottle)

Other ascitic fluid tests:

 Total protein level

 Albumin level (Please mention albumin separately on form as it is required to
calculate the serum–ascites albumin gradient, SAAG). Remember to send serum
albumin at the same time/same day
 Glucose level
 Amylase level (elevation suggests pancreatic source)
 Cytology if malignancy is suspected. (send several hundred mls of fluid)

Send ascitic fluid in a sterile (red/white top) container and a biochemistry form to CAH lab

Consent:

 Explain the procedure

 Benefits (diagnostic/therapeutic)
 Risks/complications (Pain, bleeding, infection, bowel, bladder or viscus perforation
and fluid leak)
 Alternative options (diuretics/TIPSS) to the patient or the patient's representative
 Obtain signed informed consent

Equipment:
 Iodine or chlorhexidine skin sterilizer
 Alcohol wipes x 3
 Dressing pack (gauze pieces, forceps, cotton balls, and waste collecting bag)
 Sterile drape
 Inco sheet/pad
 Sterile syringes (2x5 mL, 1x20ml)
 Needles: 2 green (19G) and one orange (25G) colour
 5 ml of Lidocaine 2%
 #11 blade scalpel (for therapeutic paracentesis only)
 Adhesive bandage/iV3000 x 2 (Cannula dressing)
 Sterile gloves x 2
 Bonnano catheter x 1
 Fluid collecting bag
 Sterile container,Purple-top (EDTA) tube, Blood culture bottles
Technique:
 Ask patient to empty bladder before starting procedure (To avoid bladder perforation)
 Supine position with head resting on pillow
 Carry out under strict sterile conditions
 Confirm ascites clinically and mark location with skin-marking pen.
 The recommended area of abdominal wall entry for paracentesis is 2-4 cm superior
and medial to the anterior superior iliac spines on either side. Use ultrasound in
difficult cases or history of previous complications

-
 Clean area with iodine

 Inject lidocaine 2% as local anaesthetic. Anaesthetise skin with orange needle and
raise a skin bleb. Anaesthetise deeper tissues with green needle. Use a maximum of
10ml of lidocaine.
 Give a small nick to skin for introduction of Bonanno needle, if required.

 Assemble Bonanno catheter. Roll down sheath to make catheter straight, then
advance needle to the tip of catheter. Once you can see tip of needle, remove
overlying sheath from catheter.
  Insert Bonnano catheter using ‘Z’ tract technique to avoid fluid leak:

 Once you have inserted the catheter to the equivalent length of green needle where
fluid was first aspirated or you notice fluid in the cap of Bonanno, start to pull needle
back slowly while advancing catheter in with other hand. Be careful not to pull needle
out too quickly, otherwise catheter may kink in abdominal wall.

 Advance the catheter to the hilt and remove needle completely

 Fix the catheter with sterile iv3000 (cannula dressing)

 Connect to fluid collecting bag for continuous drainage

Post-procedure:
For doctors:
 Do not leave drain more than 6 hours in patients with liver cirrhosis. In patients
with malignant ascites this can be left for longer duration
 Infuse 100ml of 20% Human Albumin for every 3 litre of fluid removed. (Dose:
8gm/litre of fluid removed).
 Request albumin from laboratory on Blood and Blood Product request form (red
colour). For example: 20% Albumin 100ml x 3 bottles.
 Prescribe albumin on fluid balance chart: 100ml Human Albumin IV over 30 minutes.

For Nurses:
 Monitor BP, pulse respiration every 15 minutes for 1 hour then every 30 minutes for 1
hour then hourly for 4 hours.
 Measure and record amount of fluid drained.
Observe for any sign of haemorrhage or shock.
 If patient becomes hypotensive, clamp the drain and consider infusing 100ml of
Human Albumin.
 Do not clamp the fluid drainage while infusing albumin.
 If fluid leak occurs after removal of drain then ask patient to lie on opposite side for 2
hours. If still continues, attach a stoma bag and inform doctor.
 If no leak, discharge 30 minutes after removing drain.
  Patient should be advised to remove dressing after 48 hours.

If unsuccessful:
 Stop procedure
 Seek senior help
 Consider ultrasound for confirmation of fluid and marking of site for aspiration

References:
1. Gut. 2006 Oct; 55(Suppl 6): vi1–vi12.
2. Wong CL, Holroyd-Leduc J, Thorpe KE, Straus SE. Does this patient have bacterial
peritonitis or portal hypertension? How do I perform a paracentesis and analyse the
results? JAMA. 2008 Mar 12. 299(10):1166-78.
3. McGibbon A, Chen GI, Peltekian KM, van Zanten SV. An evidence-based manual for
abdominal paracentesis. Dig Dis Sci. 2007 Dec. 52(12):3307-15.
4. McVay PA, Toy PT. Lack of increased bleeding after paracentesis and thoracentesis
in patients with mild coagulation abnormalities. Transfusion. 1991 Feb. 31(2):164-71.
5. Romney R, Mathurin P, Ganne-Carrie N, et al. Usefulness of routine analysis of
ascitic fluid at the time of therapeutic paracentesis in asymptomatic outpatients.
Results of a multicenter prospective study. Gastroenterol Clin Biol. 2005 Mar.
29(3):275-9.
6. Cadranel JF, Nousbaum JB, Bessaguet C, et al. Low incidence of spontaneous
bacterial peritonitis in asymptomatic cirrhotic outpatients. World J Hepatol. 2013 Mar
27. 5(3):104-8.
7. Ascitic tap (paracentesis) Oxford Medical Education.

Prepared by: Dr. Kh Mumtaz Hussain, Specialty Doctor Gastroenterology.

Reviewed by: Dr. Seamus Murphy and Dr. Christophe Hillemand, Consultant
Gastroenterologists, Daisy Hill Hospital, Newry, Southern Health & Social Care Trust.