MEKELLE UNIVERSTY

COLLEGE OF HEALTH SCIENCE

AYDER REFERRAL HOSPITAL
LECTURE ON ABDOMINAL PARACENTESI
PREPARED BY
GIRMAWI MEBRAHTOM
C II
24/1/06E.C
ABDOMINAL PARACENTESIS

prepared by Girmawi.M C II
 CONTENT
Definition
Indication
Contraindication
Technique
Complication
Follow /After procedure
 cont
Paracentesis is a procedure in which a needle or catheter
is inserted into the peritoneal cavity to obtain ascitic fluid
for diagnostic or therapeutic purposes.

paracentesis can be done for

-diagnostic or
-therapeutic purpose

Diagnostic paracentesis refers to the removal of a

small quantity of fluid for testing.
 Cont
Therapeutic paracentesis refers to the
removal of 5 liters or more of fluid
To reduce and relives
- intra-abdominal pressure
-dyspnea,
-abdominal pain, and
-early satiety.
 INDICATION
1-Diagnostic tap
is used for the following:
a) New-onset ascites: Fluid evaluation helps to
determine etiology,
differentiate transudate versus exudate,
detect the presence of cancerous cells,
or
address other considerations
b) Suspected spontaneous or secondary bacterial
peritonitis
 2-Therapeutic tap
is used for the following:
a) Respiratory compromise secondary to ascites
b) Abdominal pain or pressure secondary to
ascites (including abdominal compartment syndrome)
 CONTRAINDICATION
The Contraindication
-Absolute
-Relative
 Absolute Contraindication
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.

1. 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/L 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/L 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.In these patients,
pretreatment with FFP, platelets, or both before the
paracentesis is also probably not needed
 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 air-
filled 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 linea
alba)

-5 cm superior and medial to the anterior superior iliac

spines on either side(in update 3cm)
 Contd
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.
 Equipment
Antiseptic swab sticks
Fenestrated drape
Lidocaine 1%, 5-mL ampule
Syringe, 10 mL
Injection needles, 22 gauge (ga), 2
Injection needle, 25 ga
Scalpel, no. 11 blade
Catheter, 8F, over 18 ga !
7 1/2" needle with 3-way stopcock,
self-sealing valve,
and a 5-mL Luer-Lock syringe
Syringe, 60 mL
Introducer needle, 20 ga
Tubing set with roller clamp
Drainage bag or vacuum container
Specimen vials or collection bottles, 3
Gauze, 4 ! 4 inch
Adhesive dressing
 Technique
Explain the procedure, benefits, risks, complications, and
alternative options to the patient or the patient's representative.
Obtain signed informed consent.
Empty the patient's bladder, either voluntarily or with a Foley
catheter.
Position the patient and prepare the skin around the entry site with
an antiseptic solution
 Contd
Apply a sterile fenestrated drape to create a sterile field

Use the 5-mL syringe and the 25-ga needle to raise a small
lidocaine skin wheal around the skin entry site
 Contd
Switch to the longer 20-ga needle and administer 4-5 mL of
lidocaine along the catheter insertion tract (see image below).
Make sure to anesthetize all the way down to the peritoneum. The
authors recommend alternating injection and intermittent aspiration
down the tract until ascitic fluid is noticed in the syringe. Note the
depth at which the peritoneum is entered. In obese patients,
reaching the peritoneum may involve passing through a significant
amount of adipose tissue.
 Contd
Use the No. 11 scalpel blade to make a small nick in the skin to
allow an easier catheter passage

Insert the needle directly perpendicular to the selected skin entry

point. Slow insertion in increments of 5 mm is preferred to
minimize the risk of inadvertent vascular entry or puncture of the
small bowel.
 Contd
Continuously apply negative pressure to the syringe as the needle
is advanced. Upon entry to the peritoneal cavity, loss of resistance
is felt and ascitic fluid can be seen filling the syringe .At this point,
advance the device 2-5 mm into the peritoneal cavity to prevent
misplacement during catheter advancement. In general, avoid
advancing the needle deeper than the safety mark that is present
on most commercially available catheters or deeper than 1 cm
beyond the depth at which ascitic fluid was noticed in the lidocaine
syringe.
 Contd
11 Use one hand to firmly anchor the needle and syringe securely in
place to prevent the needle from entering further into the peritoneal
cavity

12 Use the other hand to hold the stopcock and catheter and
advance the catheter over the needle and into the peritoneal cavity
all the way to the skin (see image and video below). If any
resistance is noticed, the catheter was probably misplaced into the
subcutaneous tissue. If this is the case, withdraw the device
completely and reattempt insertion. When withdrawing the device,
always remove the needle and catheter together as a unit in order
to prevent the bevel from cutting the catheter
 Contd
13 While holding the stopcock, pull the needle out. The self-sealing valve
prevents fluid leak.
Attach the 60-mL syringe to the 3-way stopcock and aspirate to
obtain ascitic fluid and distribute it to the specimen vials (see images and
video below). Use the 3-way valve, as needed, to control fluid flow and
prevent leakage when no syringe or tubing is attached.
 Contd
14 Connect one end of the fluid collection tubing to the stopcock and
the other end to a vacuum bottle or a drainage bag.
 Contd
The catheter can become occluded by a loop of bowel or omentum.
If the flow stops, kink or clasp the tubing to avert loss of suction,
then break the seal and manipulate the catheter slightly, then
reconnect and see if flow resumes. Rotating the catheter about the
long axis can sometimes reinstitute flow in models with side ports.

Remove the catheter after the desired amount of ascitic fluid has
been drained (see image below). Apply firm pressure to stop
bleeding, if present. Place a bandage over the skin puncture site.
 Complication
Failed attempt to collect peritoneal fluid
Persistent leak from the puncture site
Wound infection
Abdominal wall hematoma
Spontaneous hemoperitoneum: This rare complication is due to
mesenteric variceal bleeding after removal of a large amount of ascitic
fluid (>4 L).
Hollow viscous perforation (small or large bowel, stomach, bladder)
Catheter laceration and loss in abdominal cavity
Laceration of major blood vessel (aorta, mesenteric artery, iliac artery)
Postparacentesis hypotension
Dilutional hyponatremia
Hepatorenal syndrome
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