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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.
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DEFINITION

Paracentesis is a procedure to remove fluid from the peritoneal cavity, better described as
peritoneocentesis (“cent” meaning to pierce). Needle is inserted to peritoneal cavity to drain
peritoneal fluid. It is done basically for two purposes: diagnostic and therapeutic.

INDICATION

• Therapeutic paracentesis
➢ Therapeutic paracentesis to relieve symptoms due to increased intra-abdominal
pressure like dyspnea, poor appetite and declining urine output
➢ Percutaneous decompression of resuscitation induced abdominal compartment
syndrome related to development of acute tense ascites
• Diagnostic paracentesis
➢ New onset ascites to establish cause
➢ To diagnose a metastatic cancer
➢ To diagnose hemoperitoneum in cases of trauma
➢ Patient with pre-existing ascites now deteriorating with fever, abdominal pain
and tenderness, hepatic encephalopathy and increasing white blood
cells (WBC) count and deteriorating urine output.

CONTRAINDICATION

• Absolute contraindication
➢ Acute abdomen that requires surgery
➢ Patient with disseminated intravascular coagulation and fibrinolysis and
clinically apparent oozing from needle sticks until coagulopathy is corrected.
➢ Majority of patient who require paracentesis have underlying baseline liver
disease and, thereby associated coagulopathy and thrombocytopenia. However,
clinically important bleeding events are less in these patient groups, hence
routine use of blood products is usually nit required. There are no specific
guidelines for transfusion in such patients. However, if international normalized
ratio (INR) is higher than 2 or platelet is lower than 20.000/dL, then fresh frozen
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plasma or platelet concentrates should be considered respectively despite scanty

evidence, to support safety of patient.
• Relative contraindications
➢ Pregnancy
➢ Distended bladder
➢ Massive ileus with bowel distension
➢ Intra - abdominal adhesions
➢ Abdominal wall cellulitis
➢ Severe hypoproteinaemia
➢ Obvious infections at the intended site of infection
➢ Patient with evidence of abdominal hematoma, engorged veins
➢ Hemodynamic instability – large volume shift cause hypotension
➢ Acute kidney injury - large volume shift cause decreases renal
perfusion

APPLIED ANATOMY

• . The inferior epigastric artery runs along the rectus abdominis muscle, hence needle
insertion site should always be
selected lateral to rectus abdominis
muscle.
• Left lower quadrant is better
preferred over right lower quadrant
as critically ill patients tend to have
distended cecum.
• In practice, preferred needle
insertion site is 2-4 cm medially and
cephalic to anterior superior iliac
spine along the midclavicular line. Another needle insertion site may be along the
midline, 2 cm below the umbilicus.
• This is along the Linea alba (an avascular structure) and hence, chances of vessel injury
are not there.
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• The left lower quadrant is considerably thinner and has good depth of ascitic fluid than
the midline infraumbilical position. This is especially helpful in obese patients and
hence, left quadrant is preferred site.
• In patients with liver disease, there are significant collaterals on anterior abdominal
wall. Avoid such highly congested sites.
• In case of loculated ascites, ultrasound-guided tapping should be done.

TECHNIQUE

Paracentesis can be basically performed by three techniques:

1. Needle technique:
❖ This technique is employed frequently when only small amount of ascitic fluid
needs to be removed, that is, in diagnostic paracentesis.
❖ Usually, a 20 gauge and 1.5-inch needle is sufficient in thin and lean patients.
❖ In obese patients or patient with hick abdominal wall, an 18-20 gauge lumbar
puncture needle shall serve the purpose.
2. Catheter technique:
❖ Where large amount of fluid is to be removed (that is in therapeutic
paracentesis), catheter technique is recommended as it is cause lesser
complications.
❖ At 16–18-gauge angiocath with catheter over needle can be used.
❖ Disadvantage with angiocath is that sometimes the plastic catheter may fray
or break during insertion or removal and may require unnecessary surgery.
❖ Alternately a safer option is to use a central venous catheter
3. Ultrasound guidance technique:
❖ Ultrasound – guided puncture shall particularly be helpful in conjunction with
needle or catheter technique
❖ Specially used in patients with intra- abdominal wall adhesions, loculated
ascites and patient with deranged bleeding and coagulation parameters.
❖ It reduces the complications associated with blind needle insertion such as
perforation of bowel and bleeding.

PREPARATION

✓ Laboratory check:
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➢ Prothrombin time (PT)

➢ International normalized ratio (INR)
➢ Activated partial thromboplastin time (aPTT)
➢ Platelet count
➢ Haematocrit
✓ Monitoring:
➢ Blood pressure
➢ Electrocardiography (ECG)
✓ Always secure a good intravenous access before procedure.
✓ Medications:
An emergency medication trolly should always be ready at bedside.
✓ Equipment:
➢ Sterile gloves, gown, mask and cap
➢ 2% chlorhexidine for skin preparation
➢ Sterile drapes and sterile gauze pieces
➢ Local anaesthetic (2% xylocaine)
➢ 10 cc syringe
➢ 50 cc syringe
➢ Needles – 24 gauge and 1.5inch needle for diagnostic tap in thin and lean
patients.
- 18-20 gauge lumbar puncture needle for diagnostic tap in obese
patients.
- 16-18 gauge angiocath or single lumen central venous catheter for
therapeutic tapping.
➢ Intravenous set or a no collapsible tubing for drainage.
➢ Drainage bottles
➢ Sample tubes and bottles for hematology, chemistry, microbiology, cytology
and cultures.
✓ Patient preparation
➢ Written and informed consent should be obtained from patient and if patient is
not able to give consent then form the closest caregiver.
➢ Ensure the patient has an empty bladder prior to procedure to avoid inadvertent
injury.
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➢ Make the patient lie in bed and make sure head end of bed is raised by 30-45
degree in head up position. This allows the gas filled bowel to ascend and fluid
to gravitate at the lower dependent regions where we are intending to puncture.
➢ Adjust the height of bed so that the operator is comfortable at that level.
➢ If available, ultrasound should preferably be obtained prior to going ahead with
procedure. This shall help in documenting the exact point of puncture, depth of
fluid from skin and depth of bowel from skin and also help to identify any
loculation.
➢ If ultrasound is not available then on percussion, point of maximum dullness
should be found and accordingly puncture site should be selected.
➢ Mark the selected site.
➢ After proper hand wash and scrub and wearing sterile gown and gloves, paint
the selected site and surrounding area with 2% chlorhexidine and then cover the
area with sterile fenestrated drape.
➢ Anesthetize the skin, subcutaneous tissue and deeper tissue up to parietal
peritoneum at the selected site with 2% xylocaine with a 24 gauge and 1.5-inch
needle
➢ . Always aspirate before injecting local anaesthetic agent.

PROCEDURE

✓ Needle Technique
➢ Use a 18-20 gauge, and 1.5-inch needle for thin and lean patients or lumbar
puncture needle with similar gauge for obese patients or patients with thick
abdominal wall.
➢ Z-track technique: Pull the skin at puncture site taut inferiorly. While tension is
maintained on skin inferiorly, prick the skin and then enter the abdominal wall
fascia and peritoneum perpendicularly. This ensures that the site of entry of skin
and peritoneum are at different locations and, thus minimizes the chances of
ascitic fluid leak post procedure.
➢ As needle is introduced, gentle aspiration should be done intermittently.
➢ Continuous aspiration may pull bowel or omentum onto the needle tip,
occluding the tip.
➢ This may give the false impression that there is no fluid.
➢ If bowel or omentum is pulled to the needle tip, releasing the suction on the
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syringe plunger may allow the bowel or omentum to float away and permit
aspiration with free flow of fluid into the needle and syringe.
➢ Aspiration of fluid suggests that peritoneal cavity has been entered.
➢ Now stabilize the needle with one hand and change the syringe to a 50 cc syringe
to collect samples for investigation.
➢ In case needle technique is used for therapeutic drainage then, connect the
needle to an intravenous set or rigid tubing which is then connected to a simple
bottle and allowed to drain with gravity or one may also use a vacuum container
✓ Catheter Technique
➢ If the patient is thin and lean then a 18-20 gauge angiocath can be used as a
catheter over needle assembly.
➢ In case of obese patients and thick abdominal wall patients a single lumen central
venous catheter can be inserted using Seldinger technique.
➢ The peritoneal cavity is entered with angiocath using similar Z-track technique,
while, continuously aspirating as we enter.
➢ As soon as ascitic fluid is aspirated the catheter is advanced and needle
withdrawn.
➢ Now, the catheter is connected to intravenous set or rigid tubing and fluid is
allowed to drain with gravity.
➢ When Seldinger technique is used in patients with large abdominal wall, initial
access to peritoneal cavity is obtained with the help of 18 gauge needle with
similar Z-track technique.
➢ Once the peritoneal cavity is accessed, then a guidewire is inserted through the
needle and gradually the needle is removed.
➢ Subsequently, single lumen central venous catheter is guided over the wire.
➢ Then after removing guidewire, the catheter is connected to a draining bottle
with the help of intravenous set or rigid tubing.
➢ It is very important to use Z-track technique for Seldinger technique or else there
can be high possibility of post-procedure leak from the puncture site.
✓ Ultrasound-guided Technique
➢ Under select circumstances as mentioned earlier paracentesis may be done using
ultrasound guidance.
➢ Needle technique or catheter technique is used in conjunction with ultrasound
to accurately localize the fluid in peritoneal cavity.
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COLLECTION OF FLUID FOR LABORATORY TESTING

➢ Once fluid is aspirated in syringe, we change over to a 50 cc syringe and aspirate

the ascitic fluid.
➢ This syringe is then handed over to an assistant who is wearing nonsterile gloves.
A new 22 gauge is then attached to the syringe with sample. 1-2 mL of sample
of fluid is the collected in tube with anticoagulant (this tube usually has purple
cap) and 1-2 mL of fluid is collected in a plain tube (this tube usually has red
cap).
➢ If cultures are needed then blood culture bottles are used for inoculation of
ascitic fluid.
➢ It is important to use blood culture bottles because spontaneous bacterial
peritonitis (SBP) is an infection which usually has low colony count, just like
bacteraemia.
➢ If a tube or syringe is used for sending ascitic fluid cultures, then sensitivity for
detecting SBP is dramatically decreased.
➢ The assistant wipes the culture bottle cap with alcohol swab and then connects
the needle with syringe with culture bottle.
➢ Approximately 10 mL of ascitic fluid is used to inoculate blood culture bottle.
➢ For cytology we collect the whole drained ascitic fluid specimen in a nonsterile
glass bottle and send for cytospin.
➢ Some laboratories require fluid for cytology delivered in a syringe or sterile
container.
➢ Exact sample requirements, including those for unusual tests, should always be
coordinated with local laboratory.

POST-PROCEDURE CARE

✓ Once the needle or catheter is removed, apply a sterile gauze dressing over the

puncture site and watch for any leak from the site.

✓ Patients with suspected secondary bacterial peritonitis should be investigated with

emergent radiograph of abdomen in upright position and if needed a computed
tomographic scan of the abdomen. Patient should be taken up emergency laparotomy,
if free air or a surgically-treatable source of infection is documented.
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❖ Interpretation of Fluid Analysis

Majority of times ascitic fluid analysis is done to rule out infection and for presence of portal
hypertension. To determine this, basic fluid tests that need to be done include: assessment of
appearance, total count and differential count on ascitic fluid, total protein concentration and
serum-to-ascitic albumin gradient (SAAG).

➢ Appearance:
✓ Uncomplicated ascites in background of chronic liver disease would give
clear ascitic fluid.
✓ Turbid fluid would suggest infection or bowel perforation.
✓ Milky fluid is suggestive of chylous ascites and
✓ bloody fluid may suggest either traumatic tap or malignant ascites.
➢ Total leukocyte count and differential leukocyte count:
✓ SBP is diagnosed with absolute polymorphonuclear count more than or equal
to 250 cells/mm3 in ascitic fluid and positive culture of ascitic fluid.
✓ The total leukocyte count and neutrophil counts need to be corrected in
patients with bloody samples. One white blood cell should be subtracted from
the ascitic fluid leukocyte count per every 750 RBC to yield the “corrected
total count”, and one neutrophil be subtracted from absolute
polymorphonuclear count per every 250 RBC to yield the “corrected
neutrophil count”.
➢ Serum to ascites albumin gradient:
It is more useful than the conventional exudates/transudate concept
✓ helps identify portal hypertension in such patients
✓ Ascitic fluid albumin value subtracted from the serum albumin value gives
SAAG. SAAG more than or equal to 1.1 gm/dL suggests patient has portal
hypertension. SAAG will be elevated with any disorder due to portal
hypertension.
➢ Ascitic fluid protein concentration:
Traditionally ascitic fluid can be classified as
✓ an exudate if total protein is more than or equal to 2.5-3.0 gm/dL in ascitic fluid
and a transudate if it is below this cut- off.
✓ This system of classification into transudate and exudates has been replaced
by the SAAG, which is a more useful measure.
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✓ The total protein concentration may help to differentiate uncomplicated ascites

due to liver cirrhosis from cardiac causes both of which have SAAG more than
or equal to 1.1g/dL.
✓ In cirrhotic ascites, total protein concentration is usually less than 2.5 g/dL.
✓ In ascites due to cardiac causes total protein concentration is usually more than
or equal to 2.5 g/dL.
✓ Nephrotic ascites, the total protein in ascites is usually less than 2.5 g/dL and
SAAG is more than 1.1 g/dL.
➢ Additional tests:
Few additional tests may be performed with the initial tests, if there is clinical suspicion
for a particular disorder or they may be performed later based on the results of initial
testing.
✓ Glucose concentration, lactate dehydrogenase concentration, gram stain and
culture (infection, bowel perforation)
✓ Zn-stain, adenosine deaminase activity and tuberculosis culture (tuberculous
peritonitis)
✓ Cytology and carcinoembryonic antigen level (malignancy)
✓ Triglyceride concentration (chylous ascites)
✓ Amylase concentration (pancreatic ascites or bowel perforation)
✓ Bilirubin concentration (bowel or biliary perforation).

COMPLICATION/PROBLEM

• Hypotension:
This usually occurs in large volume paracentesis (defined as >5 L fluid removed at
one sitting), where rapid mobilization of fluids from vascular space to third space
occurs and thus results in paracentesis induced circulatory dysfunction.
✓ Administer a bolus of intravenous fluids.
✓ If hypotension is persistent then, consider starting a vasopressor infusion.
✓ The American Association for study of liver disease practice guidelines
suggest, large volume paracentesis should only be done for refractory ascites.
✓ If large volume paracentesis is planned then, it may be done under cover of
intravenous albumin infusion of 6-8 gm/L of ascitic fluid to prevent such
complication.
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✓ Albumin infusion may be withheld for paracentesis volume less than 5 L. If

hypotension is not responding then, one must consider a possibility of
intraperitoneal bleed and obtain an urgent ultrasound.
• Persistent leak of ascitic fluid:
Usually, occurrence is rare. Treatment usually involves
✓ giving 5 minutes pressure over the puncture site and then apply a pressure
bandage.
✓ If still persistent, then one may consider a purse string suture to close the entry
site.
• Intraperitoneal haemorrhage:
✓ Usually suspected when the returning fluid is persistently bloody and
patient is going into hypotension and tachycardia.
✓ Correct coagulation abnormalities, if any.
✓ If still worsening, then seek a surgical opinion.
• Bowel perforation and peritonitis:
Infection is usually rare unless bowel is punctured by paracentesis needle. If initial
aspirate is fecal then one may consider this possibility. Patients usually develop
abdominal pain and signs of peritonitis.
✓ Usually, these perforations are small and get walled off by omentum and pain
gradually subsides.
✓ If there is a persistent or worsening sign of peritonitis then plan for an upright
X-ray of abdomen to look for gas under diaphragm or CT-abdomen with oral
contrast to look for extravasations.
✓ Obtain a surgical consult.

COCLUSION

Paracentesis is a relatively simple procedure performed at the bedside. The procedure is often
performed by the internist, emergency department physician, radiologist, general surgeon or
the intensivist. These patients need close monitoring by the nurses as the procedure can be
associated with hypotension, bleeding and leakage of fluid. When done for therapeutic reasons,
it can quickly relieve symptoms. However, in many cases recurrence of ascites is common and
adversely affects the quality of life
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BIBLIOGRAPHY

• Eric F. Reichman. Emergency Medicine Procedures. China Translations &Printing

services Ltd; 2nd edition 2013:421-30
• Jean – Louise Vincent. Textbook of Critical care. Elsevier India Private Ltd; 6th
edition:741-43