Diagnostic: evaluation of new onset ascites or of known ascites with concern for SBP. There is benefit to all patients with ascites receiving diagnostic paracentesis on admission to the hospital.
Therapeutic: tense ascites, refractory to diuretics, causing pt discomfort
Relative contraindications
Significant bowel distension due to ileus or SBO, hemodynamic instability (due to large fluid shifts with LVP), DIC, infection/breakdown of skin overlying puncture site
Number of bottles (can call the service center to request)
Labs: cell count w/diff, BF culture, BF and serum albumin, total protein; cytology if concerned for malignancy; BF/serum Hct if bloody
Measure skin/subQ depth with US to help choose sufficiently long needle
Supplies
For both diagnostic & therapeutic para, would recommend using the kits (obviously don’t use the catheter for diagnostic; just the supplies); it has everything you need in one place; not really saving hospital any money getting supplies separately versus just using a kit
Ultrasound with curvilinear probe
Sterile gloves
Bouffant or surgical cap, surgical mask
Pen to mark entry point
Chlorhexidine
Lidocaine/epi if high bleeding risk
Lab recommends only blood in culture bottles
Specimen cup
Vacuum bottles or wall suction canisters (if LVP, ask nurse to call down to service center for 3L canisters; rather than the 1L ones typically stocked by floors for oral wall suction)
Table
6 Fr Safe-T-Centesis Kit- Note that the 6F kit is preferred over the 8F as it has the blunt tip safety mechanism
Procedural considerations
Ultrasound Probe: curvilinear
Identify safe pocket (>2 cm deep), with no nearby bowel or adhesions. Avoid surgical scars. Attempt as lateral as possible to avoid inferior epigastric vessels.
Local anesthesia with lidocaine all the way to peritoneum, as this is most sensitive part
If only diagnostic, use 18G needle with 20-50cc syringe rather than kit
If high bleeding risk, use long 18G needle & attach to syringe instead of 6 Fr. Catheter
If hernia present, have the pt reduce it while draining fluid to prevent incarceration
Inoculate culture bottles at bedside rather than sending fluid samples to lab for inoculation to increase yield 50% → 80% (Note that VA does not allow bedside inoculation.)
Post-procedural considerations
Albumin (25%) for large volume (>5L) removal: 8 g per liter removed, up to 50 g
Ascitic leak: can try skin glue or place 1 figure-of-eight stitch with 4.0 vicryl
Bleeding: Hold pressure with quick-clot and gauze for >5-10 mins for persistent bleeding. STAT page EGS or IR if profuse bleeding or concern for organ injury
