Approach Considerations
Conventionally, paracentesis under ultrasonographic (US) guidance at hospital setup is required for ascites-related symptoms as part of palliative care. However, this may not be feasible in all scenarios, in that some patients may have difficulty in reaching the hospital. Home-based palliative paracentesis (HBPP) as an interventional palliative option is safe, effective, and convenient. This was demonstrated by Ota et al in a case series of 30 patients with ascites. [32]
Home-based abdominal paracentesis via Tenckhoff catheter in patients with refractory congestive heart failure (CHF) is an alternative to periodic percutaneous paracentesis. Kunin et al described this technique in 18 of 69 cases of refractory CHF patients on peritoneal dialysis and found that it improved the symptoms without the need for peritoneal exchanges for fluid or solute removal. [33]
Aspiration of Ascitic Fluid From Peritoneal Cavity
The video below depicts US-assisted large-volume paracentesis (LVP). The description that follows outlines the steps in the procedure.
Ensure that the patient's bladder is empty, either through voluntary emptying on the part of the patient or through the use of a Foley catheter.
Position the patient, and prepare the skin around the entry site with an antiseptic solution (see the first image below). Apply a sterile fenestrated drape to create a sterile field (see the second image below).
Use the 5-mL syringe and the 25-gauge needle to raise a small lidocaine skin wheal around the skin entry site (see the image below).
Switch to the longer 20-gauge needle, and administer 4-5 mL of lidocaine along the catheter insertion tract (see the image below). Make sure to anesthetize all the way down to the peritoneum. The authors recommend alternating injection and intermittent aspiration down the tract until ascitic fluid is noticed in the syringe. Note the depth at which the peritoneum is entered. In obese patients, reaching the peritoneum may involve passing through a significant amount of adipose tissue.
Use the No. 11 scalpel blade to make a small nick in the skin to allow easier passage of the catheter (see the image below).
Insert the needle directly perpendicular to the selected skin entry point (see the image below). Slow insertion in increments of 5 mm is preferred to minimize the risk of inadvertent vascular entry or puncture of the small bowel.
Continuously apply negative pressure to the syringe as the needle is advanced. Upon entry into the peritoneal cavity, loss of resistance is felt, and ascitic fluid can be seen filling the syringe (see the image below). At this point, advance the device 2-5 mm into the peritoneal cavity to prevent misplacement during catheter advancement. In general, avoid advancing the needle deeper than the safety mark present on most commercially available catheters or deeper than 1 cm beyond the depth at which ascitic fluid was noticed in the lidocaine syringe.
Use one hand to firmly anchor the needle and syringe securely in place to prevent the needle from entering further into the peritoneal cavity (see the image below).
Use the other hand to hold the stopcock and catheter and advance the catheter over the needle and into the peritoneal cavity all the way to the skin (see the image and video below). If any resistance is noticed, the catheter was probably misplaced into the subcutaneous tissue. If this is the case, withdraw the device completely and reattempt insertion. When withdrawing the device, always remove the needle and catheter together as a unit in order to prevent the bevel from cutting the catheter.
While holding the stopcock, pull the needle out. The self-sealing valve prevents fluid leak.
Attach the 60-mL syringe to the three-way stopcock and aspirate to obtain ascitic fluid, and distribute it to the specimen vials (see the images and video below). Use the three-way valve as needed to control fluid flow and prevent leakage when no syringe or tubing is attached.
Connect one end of the fluid collection tubing to the stopcock and the other end to a vacuum bottle or a drainage bag (see the images below).
A study by Kelil et al demonstrated that the use of wall suction and plastic canisters to drain and collect fluid during image-guided therapeutic paracenteses was a safe alternative to the use of evacuated glass bottles and reduced per-procedure costs. [34]
The catheter can become occluded by a loop of bowel or omentum. If the flow stops, kink or clasp the tubing to avert loss of suction, then break the seal and manipulate the catheter slightly, and finally reconnect and see if flow resumes. Rotating the catheter about the long axis can sometimes reinstitute flow in models with side ports.
After the desired amount of ascitic fluid has been drained, remove the catheter (see the image below). Apply firm pressure to stop bleeding, if present. Place a bandage over the skin puncture site.
Complications
Complications from paracentesis may include the following:
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Failed attempt to collect peritoneal fluid
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Persistent leak from the puncture site
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Wound infection
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Abdominal-wall hematoma
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Spontaneous hemoperitoneum - This rare complication is due to mesenteric variceal bleeding after removal of a large amount of ascitic fluid (>4 L).
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Perforation of hollow viscus (small or large bowel, stomach, bladder)
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Catheter laceration and loss in abdominal cavity
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Laceration of major blood vessel (aorta, mesenteric artery, iliac artery)
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Postparacentesis hypotension
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Dilutional hyponatremia
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Hepatorenal syndrome [35]
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Subcutaneous effusion - This rare complication of paracentesis is due to ascitic fluid leakage [36]
A prospective study of 171 patients undergoing paracentesis found that "major" complications occurred in 1.6% of procedures and included five episodes of bleeding and three infections, resulting in death in two cases. Major complications were associated with therapeutic but not diagnostic procedures and tended to be more prevalent in patients with low platelet counts (< 50 × 109/L), patients who were Child-Pugh stage C, and patients with alcoholic cirrhosis. [16]
Delayed paracentesis in spontaneous bacterial peritonitis (SBP) is associated with increased mortality. A retrospective analysis of 97 patients revealed that early paracentesis reduced mortality in patients with SBP. [37] The early paracentesis was mostly ordered by the emergency physician.
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Paracentesis: standard sites.
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Ultrasonogram showing ascites.
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Paracentesis. Application of antiseptic solution.
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Paracentesis. Draping.
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Paracentesis/thoracocentesis tray.
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Paracentesis. Local anesthesia: skin wheal.
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Paracentesis. Local anesthesia: deeper injection.
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Paracentesis. Skin nick for passage of catheter.
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Paracentesis. Insertion of needle into selected skin entry point.
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Paracentesis. Filling of syringe with ascitic fluid upon peritoneal entry.
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Paracentesis. Stabilization of needle and syringe.
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Paracentesis. Advancing catheter over needle.
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Paracentesis. Sample collection.
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Peritoneal fluid in vials.
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Paracentesis. Connection of collecting tube.
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Paracentesis. Drainage of ascitic fluid into vacuum bottle.
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Paracentesis. Catheter removal.
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Paracentesis. Advancement of catheter over needle.
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Paracentesis. Sample collection.
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Ultrasound-assisted large-volume paracentesis. Video courtesy of George Y Wu, MD, PhD.
