MEKELLE UNIVERSTY COLLEGE OF HEALTH SCIENCEAYDER REFERRAL HOSPITAL

LECTURE ON ABDOMINAL PARACENTESI PREPARED BY

GIRMAWI MEBRAHTOM

C II

24/1/06E.C

ABDOMINAL PARACENTESIS

prepared by Girmawi.M C II

CONTENT

Definition

Indication

Contraindication

Technique

Complication

Follow /After procedure

cont• Paracentesis is a procedure in which a needle or catheter

is inserted into the peritoneal cavity to obtain ascitic fluid

for diagnostic or therapeutic purposes.

• paracentesis can be done for

-diagnostic or

-therapeutic purpose

• Diagnostic paracentesis refers to the removal of a small quantity of fluid for testing.

Cont

• Therapeutic paracentesis refers to the removal of 5 liters or more of fluid

To reduce and relives

- intra-abdominal pressure

-dyspnea,

-abdominal pain, and

-early satiety.

INDICATION

1-Diagnostic tap

is used for the following:

a) New-onset ascites: Fluid evaluation helps to

determine etiology,

differentiate transudate versus exudate,

detect the presence of cancerous cells,

or

address other considerations

b) Suspected spontaneous or secondary bacterial

peritonitis

2-Therapeutic tap

is used for the following:

a) Respiratory compromise secondary to ascites

b) Abdominal pain or pressure secondary to ascites (including abdominal compartment syndrome)

CONTRAINDICATION

The Contraindication

-Absolute

-Relative

Absolute Contraindication

1. Patients with clinically apparent disseminated intravascular coagulation and oozing from needle sticks probably should not undergo paracentesis. This occurs in <1/1000 patients with ascites in our experience.

1. Primary fibrinolysis (which should be suspected in patients with large, three-dimensional bruises) is probably another contraindication. Paracentesis can be performed once the bleeding risk is reduced with treatment .

3. Paracentesis should not be performed in patients with a massive ileus with bowel distension unless the procedure is image-guided to ensure that the bowel is not entered.

4. The location of the paracentesis should be modified in patients with surgical scars so that the needle is inserted several centimeters away from the scar.

Surgical scars are associated with tethering of the bowel to the abdominal wall, increasing the risk of bowel perforation. Bowel perforation by the paracentesis needle occurs in approximately 6/1000 taps. Fortunately, it is generally well tolerated

5. an acute abdomen that requires surgery is an absolute

contraindication. .

Relative Contraindication

1) Severe thrombocytopenia

platelet count < 20 X 103/μL and

coagulopathy (international normalized ratio [INR] >2.0)

2) Pregnancy

3) Distended urinary bladder

4) Abdominal wall cellulitis

5) Distended bowel

6) Intra-abdominal adhesions

• Patients with an INR greater than 2.0 should receive fresh

frozen plasma (FFP) prior to the procedure.

• One strategy is to infuse one unit of fresh frozen plasma

before the procedure and then perform the procedure while

the second unit is infusing.

• Patients with platelet count of less than 20 X 103/μL should

receive an infusion of platelets prior to performing the

procedure.

• In patients without clinical evidence of active bleeding, routine

laboratory tests such as prothrombin time (PT), activated

partial thromboplastin time (aPTT), and platelet counts may

not be needed prior to the procedure.In these patients,

pretreatment with FFP, platelets, or both before the

paracentesis is also probably not needed

Preparation

• No need of preparation

PATIENT POSITION Usually performed with patient supine position

Rarely patient can be positioned lateral decubitus

This is used only 1-there is small amount of fluid and

2-The suspected diagnosis is crucial to the patient outcome(eg,Tb peritonitis)

The lateral decubitus position is advantageous because air-filled loops of bowel tend to float in a distended abdominal cavity.

Needle Entry Site

• The two recommended areas of abdominal wall entry for

paracentesis are as follows.

- 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(in update 3cm)

Cont’d

• The midline approach is now seldom used since most paracenteses (about 90 percent) are therapeutic and many patients are obese.

• In the past, the midline, cephalad from the umbilicus, was frequently used as the site of needle entry because of its relative avascularity. However, the recanalized umbilical vein may be present caudal to the umbilicus in the midline, an area that should be avoided.

Needle Entry Site To Avoid

The inferior epigastric artery traces from a point just lateral to the pubic tubercle (which is 2 to 3 cm lateral to the symphysis pubis), cephalad within the rectus sheath.

This artery can be 3 mm in diameter and can bleed massively if punctured with a large- caliber needle. Thus, this site should be specifically avoided.

areas near surgical scars should be avoided.

Visible veins should also be avoided.

Equipment• Antiseptic swab sticks

• Fenestrated drape

• Lidocaine 1%, 5-mL ampule

• Syringe, 10 mL

• Injection needles, 22 gauge (ga), 2

• Injection needle, 25 ga

• Scalpel, no. 11 blade

• Catheter, 8F, over 18 ga !

7 1/2" needle with 3-way stopcock,

self-sealing valve,

and a 5-mL Luer-Lock syringe

• Syringe, 60 mL

• Introducer needle, 20 ga

• Tubing set with roller clamp

• Drainage bag or vacuum container

• Specimen vials or collection bottles, 3

• Gauze, 4 ! 4 inch

• Adhesive dressing

Technique① Explain the procedure, benefits, risks, complications, and

alternative options to the patient or the patient's representative.

② Obtain signed informed consent.

③ Empty the patient's bladder, either voluntarily or with a Foley

catheter.

④ Position the patient and prepare the skin around the entry site with an antiseptic solution

Cont’d

⑤ Apply a sterile fenestrated drape to create a sterile field

⑥ Use the 5-mL syringe and the 25-ga needle to raise a small lidocaine skin wheal around the skin entry site

Cont’d

⑦ Switch to the longer 20-ga needle and administer 4-5 mL of

lidocaine along the catheter insertion tract (see 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.

Cont’d

⑧ Use the No. 11 scalpel blade to make a small nick in the skin to

allow an easier catheter passage

⑧ Insert the needle directly perpendicular to the selected skin entry

point. Slow insertion in increments of 5 mm is preferred to

minimize the risk of inadvertent vascular entry or puncture of the small bowel.

Cont’d⑩ Continuously apply negative pressure to the syringe as the needle

is advanced. Upon entry to the peritoneal cavity, loss of resistance

is felt and ascitic fluid can be seen filling the syringe .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 that is present

on most commercially available catheters or deeper than 1 cm

beyond the depth at which ascitic fluid was noticed in the lidocaine syringe.

Cont’d

11 Use one hand to firmly anchor the needle and syringe securely in place to prevent the needle from entering further into the peritoneal cavity

12 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 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

Cont’d

13 While holding the stopcock, pull the needle out. The self-sealing valve

prevents fluid leak.

Attach the 60-mL syringe to the 3-way stopcock and aspirate to

obtain ascitic fluid and distribute it to the specimen vials (see images and

video below). Use the 3-way valve, as needed, to control fluid flow and

prevent leakage when no syringe or tubing is attached.

Cont’d

14 Connect one end of the fluid collection tubing to the stopcock and

the other end to a vacuum bottle or a drainage bag.

Cont’d

• 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, then

reconnect and see if flow resumes. Rotating the catheter about the

long axis can sometimes reinstitute flow in models with side ports.

• Remove the catheter after the desired amount of ascitic fluid has

been drained (see image below). Apply firm pressure to stop bleeding, if present. Place a bandage over the skin puncture site.

Complication• 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 viscous 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

THANK YOU