Sections

Paracentesis

Periprocedural Care

Patient Education and Consent

Explain the procedure, benefits, risks, complications, and alternative options to the patient or the patient's representative, and obtain signed informed consent.

Equipment

The equipment required can be found in a disposable paracentesis/thoracocentesis kit (see the image below).

Paracentesis/thoracocentesis tray.

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Equipment includes the following:

Antiseptic swab sticks
Fenestrated drape
Lidocaine 1%, 5-mL ampule
Syringe, 10 mL
Injection needles, 22-gauge (two)
Injection needle, 25-gauge
Scalpel, No. 11 blade
Catheter, 8 French, over 18-gauge × 7.5-in. (19-cm) needle with three-way stopcock, self-sealing valve, and a 5-mL Luer-Lok syringe
Syringe, 60 mL
Introducer needle, 20-gauge
Tubing set with roller clamp
Drainage bag or vacuum container
Specimen vials or collection bottles (three)
Gauze, 4 × 4 in. (10 × 10 cm)
Adhesive dressing

Anesthesia

Local anesthesia with injection of lidocaine is employed. (See Technique.) For more information, see Local Anesthetic Agents, Infiltrative Administration.

Positioning

Patients with severe ascites can be positioned supine. Patients with mild ascites may need to be positioned in the lateral decubitus position, with the skin entry site near the gurney. The lateral decubitus position is advantageous because air-filled loops of bowel tend to float in a distended abdominal cavity.

The two recommended areas of abdominal wall entry for paracentesis are as follows (see the image below):

2 cm below the umbilicus in the midline (through the linea alba)
5 cm superior and medial to the anterior superior iliac spines on either side

Paracentesis: standard sites.

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The authors recommend the routine use of ultrasonography (US) to verify the presence of a fluid pocket under the selected entry site in order to increase the rate of success (see the image below).^[31]

Ultrasonogram showing ascites.

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Performing US also helps the practitioner avoid a distended urinary bladder or small-bowel adhesions below the selected entry point. To minimize complications, it is important to avoid areas of prominent veins (caput medusae), infected skin, or scar tissue.

Technique

Koyfman A, Long B. Peritoneal procedures. Roberts JR, Custalow CB, Thomsen TW, Chanmugam AS, Chudnofsky CR, DeBlieux PMC, et al, eds. Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care. 7th ed. Philadelphia: Elsevier; 2019. 875-96.
Wong CL, Holroyd-Leduc J, Thorpe KE, Straus SE. Does this patient have bacterial peritonitis or portal hypertension? How do I perform a paracentesis and analyze the results?. JAMA. 2008 Mar 12. 299 (10):1166-78. [QxMD MEDLINE Link].
Thomsen TW, Shaffer RW, White B, Setnik GS. Videos in clinical medicine. Paracentesis. N Engl J Med. 2006 Nov 9. 355 (19):e21. [QxMD MEDLINE Link].
McGibbon A, Chen GI, Peltekian KM, van Zanten SV. An evidence-based manual for abdominal paracentesis. Dig Dis Sci. 2007 Dec. 52 (12):3307-15. [QxMD MEDLINE Link].
Hanafy AS. The role of ascitic fluid viscosity in differentiating the nature of ascites and in the prediction of renal impairment and duration of ICU stay. Eur J Gastroenterol Hepatol. 2016 Sep. 28 (9):1021-7. [QxMD MEDLINE Link].
Çekiç B, Toslak IE, Şahintürk Y, Cekin AH, Koksel YK, Koroglu M, et al. Differentiating Transudative From Exudative Ascites Using Quantitative B-Mode Gray-Scale Ultrasound Histogram. AJR Am J Roentgenol. 2017 Aug. 209 (2):313-319. [QxMD MEDLINE Link].
Eitan R, Raban O, Tsoref D, Jakobson-Setton A, Sabah G, Salman L, et al. Malignant Ascites: Validation of a Novel Ascites Symptom Mini-Scale for Use in Patients With Ovarian Cancer. Int J Gynecol Cancer. 2018 Jul. 28 (6):1162-1166. [QxMD MEDLINE Link].
Kuiper JJ, van Buuren HR, de Man RA. Ascites in cirrhosis: a review of management and complications. Neth J Med. 2007 Sep. 65 (8):283-8. [QxMD MEDLINE Link].
Lutz P, Goeser F, Kaczmarek DJ, Schlabe S, Nischalke HD, Nattermann J, et al. Relative Ascites Polymorphonuclear Cell Count Indicates Bacterascites and Risk of Spontaneous Bacterial Peritonitis. Dig Dis Sci. 2017 Sep. 62 (9):2558-2568. [QxMD MEDLINE Link].
Aponte EM, Katta S, O'Rourke MC. Paracentesis. Treasure Island, FL: StatPearls; 2021. [Full Text].
Huang Z, Yu SH, Liang HY, Zhou J, Yan HT, Chen T, et al. Outcome benefit of abdominal paracentesis drainage for severe acute pancreatitis patients with serum triglyceride elevation by decreasing serum lipid metabolites. Lipids Health Dis. 2016 Jun 24. 15:110. [QxMD MEDLINE Link]. [Full Text].
Bureau C, Adebayo D, Chalret de Rieu M, Elkrief L, Valla D, Peck-Radosavljevic M, et al. Alfapump® system vs. large volume paracentesis for refractory ascites: A multicenter randomized controlled study. J Hepatol. 2017 Nov. 67 (5):940-949. [QxMD MEDLINE Link].
Allen R, Sarani B. Evaluation and management of intraabdominal hypertension. Curr Opin Crit Care. 2020 Apr. 26 (2):192-196. [QxMD MEDLINE Link].
Wittmer VL, Lima RT, Maia MC, Duarte H, Paro FM. RESPIRATORY AND SYMPTOMATIC IMPACT OF ASCITES RELIEF BY PARACENTESIS IN PATIENTS WITH HEPATIC CIRRHOSIS. Arq Gastroenterol. 2020 Jan-Mar. 57 (1):64-68. [QxMD MEDLINE Link]. [Full Text].
McVay PA, Toy PT. Lack of increased bleeding after paracentesis and thoracentesis in patients with mild coagulation abnormalities. Transfusion. 1991 Feb. 31 (2):164-71. [QxMD MEDLINE Link].
De Gottardi A, Thévenot T, Spahr L, Morard I, Bresson-Hadni S, Torres F, et al. Risk of complications after abdominal paracentesis in cirrhotic patients: a prospective study. Clin Gastroenterol Hepatol. 2009 Aug. 7 (8):906-9. [QxMD MEDLINE Link].
Chinnock B, Fox C, Hendey GW. Gram's stain of peritoneal fluid is rarely helpful in the evaluation of the ascites patient. Ann Emerg Med. 2009 Jul. 54 (1):78-82. [QxMD MEDLINE Link].
Romney R, Mathurin P, Ganne-Carrié N, Halimi C, Medini A, Lemaitre P, et al. Usefulness of routine analysis of ascitic fluid at the time of therapeutic paracentesis in asymptomatic outpatients. Results of a multicenter prospective study. Gastroenterol Clin Biol. 2005 Mar. 29 (3):275-9. [QxMD MEDLINE Link].
Cadranel JF, Nousbaum JB, Bessaguet C, Nahon P, Nguyen-Khac E, Moreau R, et al. Low incidence of spontaneous bacterial peritonitis in asymptomatic cirrhotic outpatients. World J Hepatol. 2013 Mar 27. 5 (3):104-8. [QxMD MEDLINE Link]. [Full Text].
Mercadante S, Intravaia G, Ferrera P, Villari P, David F. Peritoneal catheter for continuous drainage of ascites in advanced cancer patients. Support Care Cancer. 2008 Aug. 16 (8):975-8. [QxMD MEDLINE Link].
Kwok CS, Krupa L, Mahtani A, Kaye D, Rushbrook SM, Phillips MG, et al. Albumin reduces paracentesis-induced circulatory dysfunction and reduces death and renal impairment among patients with cirrhosis and infection: a systematic review and meta-analysis. Biomed Res Int. 2013. 2013:295153. [QxMD MEDLINE Link]. [Full Text].
Szkodziak PR, Czuczwar P, Wrona W, Paszkowski T, Szkodziak F, Woźniak S. Ascites Index - a novel technique to evaluate ascites in ovarian hyperstimulation syndrome: a concept-proof study. Ginekol Pol. 2018. 89 (4):183-189. [QxMD MEDLINE Link]. [Full Text].
Ginès A, Fernández-Esparrach G, Monescillo A, Vila C, Domènech E, Abecasis R, et al. Randomized trial comparing albumin, dextran 70, and polygeline in cirrhotic patients with ascites treated by paracentesis. Gastroenterology. 1996 Oct. 111 (4):1002-10. [QxMD MEDLINE Link].
Shrestha DB, Budhathoki P, Sedhai YR, Baniya R, Awal S, Yadav J, et al. Safety and efficacy of human serum albumin treatment in patients with cirrhotic ascites undergoing paracentesis: A systematic review and meta-analysis. Ann Hepatol. 2021 Dec. 26:100547. [QxMD MEDLINE Link]. [Full Text].
Li H, Sun Z, Odo N, Keshavamurthy JH, Agarwal S. Effect of large volume paracentesis performed just prior to transjugular intrahepatic portosystemic shunt on the anesthetic management during the procedure. J Anaesthesiol Clin Pharmacol. 2021 Jan-Mar. 37 (1):43-46. [QxMD MEDLINE Link]. [Full Text].
Kim JJ, Tsukamoto MM, Mathur AK, Ghomri YM, Hou LA, Sheibani S, et al. Delayed paracentesis is associated with increased in-hospital mortality in patients with spontaneous bacterial peritonitis. Am J Gastroenterol. 2014 Sep. 109 (9):1436-42. [QxMD MEDLINE Link].
Orman ES, Hayashi PH, Bataller R, Barritt AS 4th. Paracentesis is associated with reduced mortality in patients hospitalized with cirrhosis and ascites. Clin Gastroenterol Hepatol. 2014 Mar. 12 (3):496-503.e1. [QxMD MEDLINE Link]. [Full Text].
Millington SJ, Koenig S. Better With Ultrasound: Paracentesis. Chest. 2018 Jul. 154 (1):177-184. [QxMD MEDLINE Link].
Wong F, Bendel E, Sniderman K, Frederick T, Haskal ZJ, Sanyal A, et al. Improvement in Quality of Life and Decrease in Large-Volume Paracentesis Requirements With the Automated Low-Flow Ascites Pump. Liver Transpl. 2020 May. 26 (5):651-661. [QxMD MEDLINE Link].
Dembinski J, Aranovich D, Banz V, Ehmann T, Klein I, Malago M, et al. Surgical technique for placement of the automated low flow ascites pump (Alfapump). Langenbecks Arch Surg. 2020 Feb. 405 (1):117-123. [QxMD MEDLINE Link].
Nazeer SR, Dewbre H, Miller AH. Ultrasound-assisted paracentesis performed by emergency physicians vs the traditional technique: a prospective, randomized study. Am J Emerg Med. 2005 May. 23 (3):363-7. [QxMD MEDLINE Link].
Ota KS, Schultz N, Segaline NA. Palliative Paracentesis in the Home Setting: A Case Series. Am J Hosp Palliat Care. 2021 Aug. 38 (8):1042-1045. [QxMD MEDLINE Link].
Kunin M, Mini S, Abu-Amer N, Beckerman P. Regular at-home abdominal paracentesis via Tenckhoff catheter in patients with refractory congestive heart failure. Int J Clin Pract. 2021 Dec. 75 (12):e14924. [QxMD MEDLINE Link].
Kelil T, Shyn PB, Wu LE, Levesque VM, Kacher D, Khorasani R, et al. Wall suction-assisted image-guided therapeutic paracentesis: a safe and less expensive alternative to evacuated bottles. Abdom Radiol (NY). 2016 Jul. 41 (7):1333-7. [QxMD MEDLINE Link].
Duggal P, Farah KF, Anghel G, Marcus RJ, Lupetin AR, Babich MM, et al. Safety of paracentesis in inpatients. Clin Nephrol. 2006 Sep. 66 (3):171-6. [QxMD MEDLINE Link].
Otsuka Y, Nagaoka H, Nakano Y, Sakae H, Hasegawa K, Otsuka F. Subcutaneous edema as rare complication of abdominal paracentesis. Clin Case Rep. 2021 Nov. 9 (11):e05116. [QxMD MEDLINE Link]. [Full Text].
Abdu B, Akolkar S, Picking C, Boura J, Piper M. Factors Associated with Delayed Paracentesis in Patients with Spontaneous Bacterial Peritonitis. Dig Dis Sci. 2021 Nov. 66 (11):4035-4045. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

Paracentesis: standard sites.
Ultrasonogram showing ascites.
Paracentesis. Application of antiseptic solution.
Paracentesis. Draping.
Paracentesis/thoracocentesis tray.
Paracentesis. Local anesthesia: skin wheal.
Paracentesis. Local anesthesia: deeper injection.
Paracentesis. Skin nick for passage of catheter.
Paracentesis. Insertion of needle into selected skin entry point.
Paracentesis. Filling of syringe with ascitic fluid upon peritoneal entry.
Paracentesis. Stabilization of needle and syringe.
Paracentesis. Advancing catheter over needle.
Paracentesis. Sample collection.
Peritoneal fluid in vials.
Paracentesis. Connection of collecting tube.
Paracentesis. Drainage of ascitic fluid into vacuum bottle.
Paracentesis. Catheter removal.
Paracentesis. Advancement of catheter over needle.
Paracentesis. Sample collection.
Ultrasound-assisted large-volume paracentesis. Video courtesy of George Y Wu, MD, PhD.

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Author

Gil Z Shlamovitz, MD, FACEP Professor of Clinical Emergency Medicine, Keck School of Medicine of the University of Southern California; Chief Medical Information Officer, Keck Medicine of USC

Gil Z Shlamovitz, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Nirav R Shah, MD, MPH Senior Scholar, Stanford University School of Medicine

Nirav R Shah, MD, MPH is a member of the following medical societies: American College of Physicians, New York Academy of Medicine, Society of General Internal Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center

Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FFST(Ed), FIMSA, MAMS, MASCRS Dean (Academic) and Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FFST(Ed), FIMSA, MAMS, MASCRS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society of Colon and Rectal Surgeons, Fellow of the Faculty of Surgical Trainers (RCSEd), Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh, Royal College of Surgeons of England, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Additional Contributors

Andrew K Chang, MD, MS Vincent P Verdile, MD, Endowed Chair in Emergency Medicine, Professor of Emergency Medicine, Vice Chair of Research and Academic Affairs, Albany Medical College; Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Attending Physician, Department of Emergency Medicine, Montefiore Medical Center

Andrew K Chang, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American Academy of Pain Medicine, American College of Emergency Physicians, American Geriatrics Society, American Pain Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The Chief Editor would like to acknowledge the assistance of Dr Gurushankari Balakrishnan, Surgical Oncology Resident, Cancer Institute (WIA), Adyar, Chennai, India; and of Dr Mohsina Subair, former Senior Resident, Department of Surgery, Dr Archana Elangovan, former Senior Resident, Department of Surgery, and Dr Evangeline Mary Kiruba Samuel, Junior Resident, Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Pondicherry, India, in updating the review of this article.

Medscape Drugs & Diseases also thanks George Y Wu, MD, PhD, Professor, Department of Medicine, Director, Hepatology Section, Herman Lopata Chair in Hepatitis Research, University of Connecticut School of Medicine, for assistance with the video contribution to this article.

Paracentesis Periprocedural Care

Patient Education and Consent

Equipment

Patient Preparation

Anesthesia

Positioning

References

Tables

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