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.
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 ask the floor clerk to request from the service center)
Labs: cell count w/diff, BF culture, BF and serum albumin, total protein; cytology if concerned for malignancy (~100 mL); BF/serum Hct if bloody
Measure skin/subQ depth with US to help choose sufficiently long needle (needle length is typically 3.5cm)
AKI: consider discussion with nephrology +/- hepatology about volume removal and albumin repletion if present
Supplies
For both diagnostic & therapeutic para, would recommend using the kits (not the catheter will not be used in the diagnostic, just the 20G needle)
Ultrasound with curvilinear probe
Sterile gloves
Cap & mask
Pen or syringe to mark entry point
Chlorhexidine
Lidocaine/epi if high bleeding risk
Specimen cup (cytology) or lavender tube for BF Hct
Vacuum bottles or wall suction canisters (if canisters are used ask floor staff to assist by calling the service center for 3L canisters)
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. Consider vascular probe to ensure no overlying vessels. 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
Kit: 6 Fr Safe-T-Centesis Kit, specimen cup
If hernia present, have the pt reduce it while draining fluid to prevent incarceration
Post-procedural considerations
Albumin (25%) for large volume (>5L) removal: 8 g per liter removed, up to 50 g; and should be strongly considered for patients with AKI/CKD, hemodynamic instability or hyponatremia regardless of volume removed
Ascitic leak: can try skin glue (mastitol, dermabond) if very small and allow to dry before placing band-aid. If leak is larger consider placing a figure-of-eight stitch with 4.0 vicryl (absorbable), if needed, additional stitches can be placd until leak resolves
Bleeding: Hold pressure with Quikclot gauze for >5-10 mins for persistent bleeding. STAT page EGS or IR if profuse bleeding or concern for organ injury
