Proper pt positioning greatly improves the ease with which a paracentesis can be performed. The pt should be instructed to lie supine with the head of the bed elevated to 45°. This position should be maintained for ~15 min to allow ascitic fluid to accumulate in the dependent portion of the abdomen. Although not generally needed, ultrasound can be helpful for documenting ascites and identifying the locations of peritoneal fluid.

The preferred entry site for paracentesis is a midline puncture halfway between the pubic symphysis and the umbilicus; this correlates with the location of the relatively avascular linea alba. The midline puncture should be avoided if there is a previous midline surgical scar, because neovascularization may have occurred. Alternative sites of entry include the lower quadrants, lateral to the rectus abdominis, but caution should be used to avoid collateral blood vessels that may have formed in pts with portal hypertension.

The skin is prepped and draped in a sterile fashion. The skin, the subcutaneous tissue, and the abdominal wall down to the peritoneum should be infiltrated with an anesthetic agent. The paracentesis needle with an attached syringe is then introduced in the midline perpendicular to the skin. To prevent leaking of ascitic fluid, “Z-tracking” can sometimes be helpful: After penetrating the skin, the needle is inserted 1-2 cm before advancing further. The needle is then advanced slowly while continuous aspiration is performed. As the peritoneum is pierced, the needle will “give” noticeably. Fluid should flow freely into the syringe soon thereafter. For a diagnostic paracentesis, removal of 50 mL of ascitic fluid is adequate. For a large-volume paracentesis, direct drainage into large vacuum containers using connecting tubing is a commonly utilized option.

After all samples have been collected, the paracentesis needle should be removed and firm pressure applied to the puncture site.