ABDOMINAL PARACENTHESIS

DEFINITION- Abdominal paracentesis is a bed side clinical procedure in which needle is

inserted into peritoneal cavity and ascitic fluid is removed.
OR
Abdominal paracentesis is define as the insertion of needle or cannula with trocar into the abdominal
wall to remove of fluid in peritoneal cavity.

TYPES
1. diagnostic small quantity of fluid is removed for testing.
2. therapeutic:>5 litres of fluid is removed to reduce intraabdominal pressure and relieve
the associate. Symptoms like dyspnoea, abdominal pain and early satiety.

INDICATION
a. For evaluation of new onset ascites.
b. Testing of ascitic fluid.
c. For evaluation of patients with ascites who has signs of clinical deterioration like
fever, abdominal pain , hepatic encephalopathy ,decreased renal function n metabolic
acidosis.
d. Paracentesis can identify unexpected diagnosis such as hemorrhagic or esinophilic
ascites useful to know etiology and antibiotic susceptibility.
CONTRAINDICATIONS

1. Patient with disseminated Intravascular Coagulation – risk is decreased by

administering platelets or FFPs.
2. Primary fibrinolysis (patient with 3 dimensional bruises) treat with aminocaproic acid
or IV tranexamic acid. Massive ileus with bowel distension. Near the surgical scar
because scars are asso. With tethering of bowel to abdominal wall n will cause bowel
perforation. Infections
3. Abnormal coagulation studies like increased INR n Thrombocytopenia are not
contraindications. 70% pts with Ascites have abnormal PT but risk of bleeding is low.
Pt who bleed had renal failure suggesting qualitative platelet dysfunction asso. With
renal failure. Here desmopressin may be used before paracentesis in pts with cirrhosis
and renal failure.

PATIENT PREPRATION

Explain the procedure & Obtain Consent No fasting before Procedure.

EQUIPMENT AND STAFF

 Clinician & Assistant

 Bottles should be labelled for tests prior doing paracentesis
 Bacterial culture is done in pts with SBP

ARTICLES
 A STERILE TRAY CONTAINING
 SPONGE HOLDING FORCEPS
 5 ML SYRINGE
 20 ML SYRINGE
 BETADINE SOLUTION
1. 7. ◦THREE WAY ADAPTER AND TUBING ◦SMALL BOWLS ◦SPECIMEN BOTTLE ◦STERILE DRESSING
PACK ◦COTTON BALLS
2. 8. A CLEAN TRAY CONTAINING: ◦MACKINTOSH AND DRAW SHEET ◦INJECTION 2 % LIGNOCAINE
◦INTRAVENOUS SET ◦KIDNEY TRAY AND PAPER BAG.

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.
KIMBERLY – CLARK QUICK TAP PARACENTESIS TRAY CONTAINS CADWELL
NEEDLE which has a sharp inner trocar & blunt outer metal cannula with side holes to
permit withdrawal of fluid if end hole is occluded by bowel.

POSITION
 Mostly Supine
 Head may be elevated
 Knee elbow position for removal of minimal fluid in dependent area.

SITE
  Lt lower Quadrant (Dullness on percussion) 3cm medial & 2cm above the ant. Sup.
Iliac spin.
 Not near umbilicus because of presence of collateral vessels.
 scars & visible veins should be avoid Surgical

SKIN STERLIZATION

 Mark the site as “X” & positions 12, 3, 6, 9 a few cm from “X”
 Sterilise with Iodine or Chlorhexidine Solution starting from X using widening
circular motions.

LOCAL ANESTHESIA
 Anaesthetise using 3- 5 ml of 1% Lignocaine Solution in a “Z” track technique.
 Needle used for it is 1.5inch which is sufficiently long.
 Choose the site & pass the needle tangentially, raising a wheal with Lignocaine. “Z”
track creates a nonlinear pathway b/n Skin& Ascitic fluid & minimise the chance of
leakage.

 With one hand pull the abdominal wall and with other hand operate the syringe. Hand
on the abdominal wall should not be removed until the needle enters the fluid.
 Insert the needle n syringe 5mm deep.
 Pull the plunger back with each advancement to see if any blood is aspirated.
 Then inject the lignocaine solution.
  the same procedure until the needle enters fluid.
 Aspiration should be intermittent not continuous.
 may pull the bowel onto needle tip, occluding the tip.
 Yellow colour fluid indicates needle is in the peritoneal cavity.

NEEDLE INSERTION:
Needle is inserted along anesthetised pathway after nick is given with 11 no. blade. Fluid
should drip from the hub of the needle.
 Larger the nick greater the post paracentesis leak.
 Ultrasound guidance cab be used to guide the procedure.
 During laproscopy parietal peritoneum may form tenting over needle n fluid doesn’t
come.
 Operator can`t see this n may mis interpret as DRY TAP.
 Rotating the needle for 90 degrees or more will pierce the peritoneum n help the
drainage.

INITIATING FLOW OF FLUID

 Small amount of fluid may be difficult to drain because bowel may block the end of
needle. So multi hole needles are helpful.
 Misconception of poor flow is LOCULATION.
 True loculation is seen in peritoneal carcinomatosis with malignant adhesions or
bowel rupture with surgical peritonitis.
 Loculation never occur in cirrhosis or heart failure with ascites or SBP.
 Stable needle n depth of penetration of needle are crucial for successful paracentesis.

TESTING
 25 ml fluid is enough for cell count, diff count ,chemical testing and bacterial culture.
 In TB 50ml for cytology
 50ml for smear n culture.

LARGE VOLUME PARACENTESIS

 It is removal of >5 lit of fluid.

 In refractory ascites ,removal of as much fluid as possible with sod .restricted diet n
diuretics will extend the interval to next paracentesis.
REMOVAL OF NEEDLE:
Needle is removed with one rapid smooth withdrawal motion.
Distract the patient by asking him to cough because cough will prevent pain sensation.

COMPLICATIONS
 Ascitic fluid leak:
-improper Z track
-using large bore needle
-large skin nick
Rx: keep ostomy bag over nick.
 Bleeding: -artery or vein
 In inferior epigastric bleed fig. of 8 suture is placed surrounding the needle site.
 Rarely laprotomy is needed to control bleeding in pts with renal failure n
hyperfibrinolysis.
 Bowel perforation
 Infections  Catheter residue broken into abdominal wall.

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