Topic

• Introduction
• Indications
• Contraindications
• Procedure
• Coding Information

Figure(s)

• Insertion Sites
• Lateral Site
• Midline Site
• Peritoneal Lavage

• Abdominal paracentesis is a safe and effective diagnostic and therapeutic procedure. Therapeutic paracentesis is used to relieve respiratory difficulty due to increased intraabdominal pressure caused by ascites.
• The left-lateral approach avoids air-filled bowel that usually floats in ascitic fluid. The patient is placed in the supine position and slightly rotated to the side of the procedure to further minimize the risk of perforation during paracentesis.
• Obtain abdominal radiographs before paracentesis, because air may be introduced during the procedure and may interfere with interpretation. It is unnecessary to perform abdominal U/S before paracentesis, except in cases of diagnostic uncertainty.
• The bladder and stomach may need to be emptied to decrease the risk of perforation of these organs. Other possible complications of paracentesis include bowel perforation, laceration of a major blood vessel, loss of the catheter or guide wire in the peritoneal cavity, abdominal wall hematomas, pneumoperitoneum, bleeding, perforation of the pregnant uterus, and infection.
• Most ascetic fluid reaccumulates rapidly. Some experts recommend that not >1.5 L of fluid be removed in any single procedure.
• Patients with severe hypoproteinemia may lose additional albumen into reaccumulations of ascites fluid and develop acute hypotension and heart failure. Cancer patients with malignant effusions may also need repetitive therapeutic paracentesis. IV fluid and vascular volume support may be required in these patients if larger volumes are removed.
• After diagnostic paracentesis, send fluid to the lab for Gram's stain; culture; cytology; protein, glucose, and lactate dehydrogenase levels; and blood cell count with differential cell count.
  • Polymorphonuclear cell count >500 cells/mm³ is highly suggestive of bacterial peritonitis.
  • Elevated peritoneal fluid amylase level or level greater than serum amylase level is found in pancreatitis.
  • Grossly bloody fluid in the abdomen indicates more severe trauma.

• Evaluation of ascites
• Evaluation of blunt or penetrating abdominal injury
• Relief of respiratory distress due to increased intraabdominal pressure
• Evaluation of acute abdomen
• Evaluation of acute or spontaneous peritonitis
• Evaluation of acute pancreatitis

• Acute abdomen requiring immediate surgery (absolute contraindication)
• Coagulopathy or thrombocytopenia (relative contraindication)
• Severe bowel distention (use extra caution)
• Multiple previous abdominal operations
• Pregnancy (absolute to midline procedure)
• Distended bladder that cannot be emptied with Foley catheter (relative contraindication)
• Obvious infection at intended site of insertion (relative contraindication)
• Severe hypoproteinemia (relative contraindication)

• Place the patient in a horizontal supine position and tilt him or her slightly to the side of collection (usually left lower quadrant). Slightly rotate the hip down on the table on the side of the needle insertion to make that quadrant of the abdomen more dependent. Insertion sites and abdominal wall anatomy are shown in Fig. 5-1.
• Prep the skin with povidone-iodine solution and allow it to dry while applying sterile gloves and mask. Center a sterile drape about one-third of the distance from the umbilicus to the anterior iliac crest.
• Infiltrate the skin and subcutaneous tissues with 1% solution of lidocaine with epinephrine. Then insert a 2-in. needle perpendicular to the skin to infiltrate the deeper tissues and the peritoneum with anesthetic.
• Insert 18-gauge, 2-in. angiocatheter through skin. Nondominant hand then stretches skin to 1 side of puncture site, and the needle is further inserted to create a Z tract (Fig. 5-2A). Release pressure on the skin after the needle enters the peritoneum.
• Advance the catheter until a "pop'' is felt and the catheter penetrates the peritoneum (Fig. 5-2B). Remove the stylette, attach to a Luer-Lock 20-mL syringe, and advance the catheter into the abdominal cavity (Fig. 5-2C).
• Draw fluid into the syringe. If no fluid returns, rotate, slightly withdraw, or advance the catheter until fluid is obtained. If still no fluid returns, abort the procedure, and try an alternative site or method. Use large Luer-tipped syringes or syringe and 1-way valve or stopcock to remove additional fluid.
• If lavage is desired—e.g., for detecting hemoperitoneum after trauma—make a 3- to 5-mm skin incision (i.e., large enough to allow threading lavage catheter) in the midline 5 cm below the umbilicus. In a similar manner to that previously described, insert an 18-gauge needle attached to a 20-mL syringe into the peritoneum while applying slight suction to the syringe (Fig. 5-3). Collect fluid in the syringe as described earlier.
• Pitfall: Maintain careful control over the depth of needle penetration to help prevent accidental viscus perforation.
• Introduce a guidewire through the needle (Fig. 5-4A). If there is any resistance to wire's passage, withdraw the wire and reposition the needle until the wire feeds easily. Remove the needle after about one-half of the wire is inserted (Fig. 5-4B).
• Slide peritoneal lavage catheter over the wire using a gentle twisting motion (Fig. 5-4C). Remove the wire after the catheter is in the peritoneal cavity. Additional fluid may be aspirated before beginning lavage.
• Connect IV tubing and infuse 700–1,000 mL of Ringer's lactate or normal saline into the abdominal cavity. Clamp the tube and gently roll the patient from side to side. Then unclamp and connect tubing to a 1-L vacuum bottle or syringe with stopcock, and remove fluid. Adjust the patient's position as necessary to get as much fluid as possible returned.
• After the procedure, gently remove the catheter and apply direct pressure to the wound. Observe the characteristics of the fluid and send it for appropriate studies. If the insertion site is still leaking fluid after 5 mins of direct pressure, suture the site with a vertical mattress suture. Apply a pressure dressing.
• Pitfall: Maintain careful control over the wire to prevent it from slipping into the peritoneal cavity.
• Pitfall: Gauze dressing should be applied when rare, persistent drainage occurs.

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