Videos

Abdominal paracentesis animated demonstration

Demonstrates how to perform diagnostic and therapeutic abdominal paracentesis.

Equipment

Prepare all the equipment on a sterile trolley with the help of an assistant.

  • Sterile gloves, apron or gown

  • Eye protection (if required)

  • Sterile drapes/towels

  • Chlorhexidine or betadine

  • 1% lidocaine, a needle to inject anaesthetic (25 gauge for the skin and a 20 to 22 gauge needle for the soft tissue)

  • 18 to 22 gauge needle (diagnostic paracentesis

  • 14 to 18 gauge needle or Caldwell needle (therapeutic paracentesis)

  • 20 mL or 60 mL syringe to collect a sample of fluid

  • Gauze or bandage

  • Sample tubes (haematology, chemistry, and microbiology) and blood culture bottles

  • Collection bag or vacuum bottle (for therapeutic paracentesis)

  • Ultrasonographic equipment (if ultrasound guidance is to be used)

Contraindications

Absolute contraindications include:

  • Acute abdomen

  • Patient refusal or distress

  • Abdominal obstruction or distended bowel loops

  • Cellulitis or other skin infection overlying the puncture site

  • Coagulopathy: caution is advised in patients with severe coagulopathy and large volume paracentesis, and the procedure should be avoided in the presence of disseminated intravascular coagulation.[96] [97]​​​ Most patients with chronic liver disease have mild coagulopathy, but this is generally not considered a contraindication.[96]​​

Relative contraindications include:

  • Pregnancy (ultrasound guidance is recommended in the second or third trimester).

Surgical scarring at the puncture site:

The paracentesis site should be moved away from any area of scarring. Surgical scars can cause adherence of the bowel to the abdominal wall, increasing the risk of bowel perforation during paracentesis.

Indications

  • Exclude spontaneous bacterial peritonitis in patients with ascites presenting with worrying symptoms (e.g., abdominal pain, fever, gastrointestinal bleed, worsening encephalopathy, new or worsening renal or liver failure, hypotension, or other symptoms of infection or sepsis)

  • Identify the aetiology of new-onset ascites

  • To improve abdominal discomfort or respiratory distress in haemodynamically stable patients with tense ascites or ascites that is refractory to diuretics (large volume therapeutic paracentesis).

Complications

Complications are rare, even in patients with significant coagulopathy. Complications can include:

  • Haemorrhage

  • Prolonged leakage of ascitic fluid through the needle puncture site

  • Infection (e.g., due to contamination by the needle or skin flora)

  • Bowel perforation

  • Hypotension and possible transient hyponatremia and increased creatinine (associated with large-volume paracentesis).

Aftercare

If there is significant leakage of ascitic fluid, apply a pressure bandage.

After large volume paracentesis, monitor blood pressure for 2 to 4 hours after the procedure.

Consider the need for plasma expansion following paracentesis. Where more than 5 L of ascitic fluid has been drained, plasma expansion has been shown to improve clinical outcome.[98] [99] Hospital policies on the use of human albumin solution (HAS) may vary; refer to local policy. If the ascites is secondary to heart failure or malignancy, normal saline or Hartmann’s solution should be considered as an alternative to HAS; the volume and rate of fluid infusion is dependent on volume drained and fluid status of the patient.

Leaking from the tap/drainage site can be problematic, and this should be monitored following removal of the needle or drain. The risks of leakage may be minimised with careful technique and Z-track methods; despite this, losses may still occur and should be monitored and measured. The patient should also be monitored carefully for signs of infection and treated promptly with antibiotics if pyrexia is detected. SBP is an infection of ascitic fluid that cannot be attributed to any intra-abdominal, ongoing inflammatory, or surgically correctable condition. It is one of the most frequently encountered bacterial infections in patients with cirrhosis. An ascitic fluid ANC of greater than 250 cells/mm³ is the accepted criterion for the diagnosis of SBP.[100] Despite some changes in the epidemiology of SBP pathogens, gram-negative bacteria remain the most common pathogens in SBP. Where SBP is suspected, an ascitic tap should be performed early to obtain ANC and bacterial cultures. This allows targeted antibiotic therapy to be commenced as soon as possible.

Blood tests should be repeated the day after ascitic drainage to check the patient remains stable. If ascitic drainage has been performed in the context of end-of-life care, this may be deemed unnecessary. Generally renal function deteriorates 24 to 48 hours following large-volume paracentesis. Consider the patient’s pre-procedure renal function, the volume of fluid drained, and the fluid status of the patient at the time of the ascitic drain to inform decisions on exact timings for renal function testing.