Paracentesis Technique

Updated: Jun 29, 2017
  • Author: Gil Z Shlamovitz, MD, FACEP; Chief Editor: Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS  more...
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Technique

Aspiration of Ascitic Fluid From Peritoneal Cavity

The video below depicts ultrasound-assisted large-volume paracentesis. The description that follows outlines the steps in the procedure.

Ultrasound-assisted large-volume paracentesis. Video courtesy of George Y Wu, MD, PhD.

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).

Paracentesis. Application of antiseptic solution. Paracentesis. Application of antiseptic solution.
Paracentesis. Draping. Paracentesis. Draping.

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).

Paracentesis. Local anesthesia: skin wheal. Paracentesis. Local anesthesia: skin wheal.

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.

Paracentesis. Local anesthesia: deeper injection. Paracentesis. Local anesthesia: deeper injection.

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).

Paracentesis. Skin nick for passage of catheter. Paracentesis. Skin nick for passage of catheter.

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.

Paracentesis. Insertion of needle into selected sk Paracentesis. Insertion of needle into selected skin entry point.

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.

Paracentesis. Filling of syringe with ascitic flui Paracentesis. Filling of syringe with ascitic fluid upon peritoneal entry.

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).

Paracentesis. Stabilization of needle and syringe. Paracentesis. Stabilization of needle and syringe.

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.

Paracentesis. Advancing catheter over needle. Paracentesis. Advancing catheter over needle.
Paracentesis. Advance catheter over needle.

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.

Paracentesis. Sample collection. Paracentesis. Sample collection.
Paracentesis. Sample collection.
Peritoneal fluid in vials. Peritoneal fluid in vials.

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).

Paracentesis. Connection of collecting tube. Paracentesis. Connection of collecting tube.
Paracentesis. Drainage of ascitic fluid into vacuu Paracentesis. Drainage of ascitic fluid into vacuum bottle.

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. [18]

 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.

Paracentesis. Catheter removal. Paracentesis. Catheter removal.
Next:

Complications

Complications from paracentesis may include the following:

  • Failed attempt to collect peritoneal fluid
  • Persistent leak from the puncture site
  • Wound infection
  • Abdominal wall hematoma
  • Spontaneous hemoperitoneum - This rare complication is due to mesenteric variceal bleeding after removal of a large amount of ascitic fluid (>4 L).
  • Hollow viscus perforation (small or large bowel, stomach, bladder)
  • Catheter laceration and loss in abdominal cavity
  • Laceration of major blood vessel (aorta, mesenteric artery, iliac artery)
  • Postparacentesis hypotension
  • Dilutional hyponatremia
  • Hepatorenal syndrome [19]

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. [8]

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