Abdominal paracentesis

paracentesis procedure

1. ABDOMINAL PARACENTESIS

2. DEFINITION Abdominal paracentesis is a bed side clinical procedure in which needle is inserted into peritoneal cavity nd ascitic fluid is removed. TYPES :-1)diagnostic small quantity of fluid is removed for testing. 2) therapeutic :>5 litres of fluid is removed to reduce intraabdominal pressure and relieve the asso . Symptms like dyspnoea , abdmnl pain nd early satiety.

3. INDICATIONS For evaluation of new onset ascites . Testing of ascitic fluid. For evaluation of pt with ascitis who has signs of clinical deterioration like fever,abd.pain,hepatic encephalopathy,decreased renal function n metabolic acidosis. Paracentesis can identify unexpected diagnosis such as chylous , hemorrhagic or esinophilic ascites useful to know etiology n antibiotic susceptibility.

4. CONTRAINDICATIONS Pt with DIC – risk is decreased by administering platelets or FFPs. Primary fibrinolysis (pt with 3 dimensional bruises) treat with aminocaproic acid or IV tranexamic acid. Massive ileus with bowel distension. Near the surgical scar bcoz scars are asso . With tethering of bowel to abd.wall n will cause bowel perforation. Infections

5. Abnormal coagulation studies like increased INR n Thrombocytopenia are not contraindications. 70% pts with Ascites have abnormal PT but risk of bleeding is low. Pt who bleed had renal failure suggesting qualitative platelet dysfunction asso . With renal failure. Here desmopressin may be used before paracentesis in pts with cirrhosis and renal failure.

6. PATIENT PREPARATION Explain the procedure & Obtain Consent No fasting before Procedure EQUIPMENT & STAFF Clinician & Assistant Bottles should be labelled for tests prior doing paracentesis Bacterial culture is done in pts with SBP

7. CHOICE OF NEEDLE DIAGNOSTIC: 1.5 Inch, 22 Gauge needle For Obese :3.5 Inch, 22 Gauge spinal needle THERAPEUTIC: 15/ 16 Gauge needle to speed up the removal. KIMBERLY – CLARK QUICK TAP PARACENTESIS TRAY CONTAINS CADWELL NEEDLE which has a sharp inner trocar & blunt outer metal cannula with side holes to permit withdrawal of fluid if end hole is occluded by bowel/ Omentum

8. POSITION Mostly Supine Head may be elevated Knee elbow position for removal of minimal fluid in dependent area SITE Lt lower Quadrant (Dullness on percussion) 3cm medial & 2cm above the ant. Sup. Iliac spine Not near umbilicus bcoz of presence of collateral vessels Surgical scars & visible veins should be avoided.

9. WHY Left???? Abd . Wall is thinner. Pool of fluid is more. Pt can be rolled easily to left for drainage. WHY NOT RIGHT??? Appedicectomy scar, caecum filled with gas in pts taking lactulose . Care must be taken not to injure inferior epigastic artery which bleeds massively & which is located near pubic tubercle

10. SKIN STERILISATION Mark the site as “X” & positions 12, 3, 6, 9 a few centimeters from “X” Sterilise with Iodine or Chlorhexidine Solution starting from X using widening circular motions.

11. LOCAL ANAESTHESIA Anaesthetise using 3- 5 ml of 1% Lignocaine Solution in a “Z” track technique. Needle used for it is 1.5inch which is sufficiently long. Choose the site & pass the needle tangentially, raising a wheal with Lignocaine . “Z” track creates a non linear pathway b/n Skin& Ascitic fluid & minimise the chance of leakage.

12. With one hand pull the abdominal wall n with other hand operate the syringe. Hand on the abd.wall should not be removed untill the needle enters the fluid. Insert the needle n syringe 5mm deep pull the plunger back with each advancement to see if any blood is aspirated. then inject the lignocaine sol. Cont. the same procedure until the needle enters fluid.

13. Aspiration should be intermittent not continuous. Cont. may pull the bowel or omentum onto needle tip,occluding the tip. Yellow color fluid indicates needle is in the peritoneal cavity. NEEDLE INSERTION : Needle is inserted along anesthetised pathway after nick is given with 11 no. blade. Fliud should drip from the hub of the needle. Larger the nick greater the post paracentesis leak.

14. Ultrasound guidance cab be used to guide the procedure. During laproscopy parietal peritoneum may form tenting over needle n fluid doesn’t come. Operator cant see this n may mis interpret as DRY TAP. Rotating the needle for 90 degrees or more will pierce the peritoneum n help the drainage.

15. INITIATING FLOW OF FLUID Small amount of fluid may be difficult to drain bcoz omentum /bowel may block the end of needle. So multi hole needles are helpful. Misconception of poor flow is LOCULATION. True loculation is seen in peritoneal carcinomatosis with malignant adhesions or bowel rupture with surgical peritonitis. Loculation never occur in cirrhosis or heart failure with ascites or SBP.

16. Stable needle n depth of penetration of needle are crucial for successful paracentesis . TESTING 25 ml fluid is enough for cell count,diff count,chemical testing n bacterial culture. In TB 50ml for cytology 50ml for smear n culture.

17. LARGE VOLUME PARACENTESIS It is removal of >5 lit of fluid. In refractory ascites,removal of as much fluid as possible with sod.restricted diet n diuretics will extend the interval to next paracentesis . REMOVAL OF NEEDLE: Needle is removed with one rapid smooth withdrawal motion. Distract the pt by asking him to cough bcoz cough will prevent pain sensation.

18. COMPLICATIONS Ascitic fluid leak: -improper Z track -using large bore needle -large skin nick Rx: keep ostomy bag over nick. Bleeding: -artery or vein In inferior epigastric bleed fig. of 8 suture is placed surrounding the needle site.

19. Rarely laprotomy is needed to control bleeding in pts with renal failure n hyperfibrinolysis . Bowel perforation Infections Catheter residue broken into adb.wall .

20. Thank u….