Procedure

Paracentesis

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Paracentesis

  • Indications
  1. Symptomatic relief in Cirrhotic Ascites
  2. Diagnostic study
    1. Suspected Spontaneous Bacterial Peritonitis
    2. Examine ascitic fluid for other etiology
  • General
  1. Remove up to 4-5 L ascitic fluid
  2. Salt-poor albumin
    1. Indicated post-procedure if >5 liters removed
    2. Preparation: 25% 50 cc bottle IV
    3. Dosing
      1. 1 bottle for every 1.5L of ascitic fluid removed or
      2. 8-10 grams per liter of fluid removed
  • Labs
  1. Labs (e.g. CBC, INR, PTT) are not required prior to routine therapeutic Paracentesis (per ACG, AGA)
    1. Paracentesis is a procedure at low risk of bleeding complications
    2. May consider labs when there is a change in clinical status (e.g. new weakness)
  2. May consider Platelet Transfusion if Platelet Count<20,000
    1. Transfuse 6 pack of Platelets before Paracentesis
    2. Consider Diphenhydramine 50 mg IV, 30 min before Platelets
  • Procedure
  1. Preparation
    1. Place Foley and empty Bladder before procedure
    2. Patient at 30 degrees head up (reverse Trendelenburg)
  2. Sites
    1. Avoid the rectus sheath
    2. Midline at Linea Alba
      1. Midline at approximately 2 cm below Umbilicus
    3. Lower quadrants (RLQ or LLQ) lateral to rectus sheath
      1. Perform under Ultrasound guidance
  3. Prepare site
    1. Clean and prep site well
      1. Spontaneous Bacterial Peritonitis risk
    2. Local 1% Lidocaine Anesthetic
  4. Paracentesis
    1. Use 22 gauge needle with catheter
    2. Consider Z-Tracking needle on entry into Abdomen
    3. Use vacuum bottle to apply suction
  5. Labs to send ascitic fluid for a diagnostic Paracentesis
    1. Cytology (if malignancy suspected)
    2. Cultures (rule-out SBP)
      1. Rule-out Spontaneous Bacterial Peritonitis
    3. Neutrophils (PMNs)
      1. Suggests Spontaneous Bacterial Peritonitis if >250/mm3 in Cirrhotic Ascites
    4. Serum-to-Ascites Albumin Gradient (SAAG)
      1. Subtract ascitic fluid albumin from Serum Albumin
      2. SAAG >1.1 g/dl suggests Portal Hypertension
  1. Always send ascitic fluid for white cell count and Neutrophil Count (PMN Count)
    1. Add culture if total white cell count >500/mm3 (or PMNs >250/mm3)
    2. In Cirrhotic Ascites, 40% of patients are asymptomatic of Spontaneous Bacterial Peritonitis
  2. Up to 4-6 liters may be safely removed per Paracentesis without albumin replacement
    1. Risk of Paracentesis-induced circulatory dysfunction (PICD) with >6 Liter Paracentesis
    2. Replace albumin if >6 Liters are removed or patient is hypotensive after procedure
  • Adverse Effects
  1. Hyponatremia
  2. Hypotension
    1. Replace albumin (esp. after large volume Paracentesis)
  3. Bleeding
    1. Any blood in peritoneal fluid should soon clear as Paracentesis continues
    2. Persistent blood in peritoneal fluid is abnormal
      1. Stop procedure and withdraw catheter
      2. Obtain serial Hemoglobins
      3. Consider CTA Abdomen
  • References
  1. Swaminathan and Shoenberger (2025) Case of the Week: Management of Cirrhotic Ascites and Paracentesis, EM:Rap, 4/7/2025