abdominal paracentesis.pdf

Abdominal paracentesis

2. Abdominal paracentesisis a bed side clinical
procedure in which needle is inserted into
peritoneal cavity ndasciticfluid is removed.
TYPES:-1)diagnostic small quantity of fluid is
removed for testing.
2) therapeutic:>5 litresof fluid is removed to
reduce intraabdominalpressure and
relieve the asso. Symptmslike dyspnoea,
abdmnlpain ndearly satiety.

3. For evaluation of new onset ascites.
Testing of asciticfluid.
For evaluation of pt with ascitiswho has
signs of clinical deterioration like
fever,abd.pain,hepatic
encephalopathy,decreasedrenal function n
metabolic acidosis.
Paracentesiscan identify unexpected
diagnosis such as chylous, hemorrhagic or
esinophilicascitesuseful to know etiology n
antibiotic susceptibility.

4. Pt with DIC –risk is decreased by
administering platelets or FFPs.
Primary fibrinolysis(pt with 3 dimensional
bruises) treat with aminocaproicacid or IV
tranexamicacid.
Massive ileuswith bowel distension.
Near the surgical scar bcozscars are asso.
With tethering of bowel to abd.walln will
cause bowel perforation.
Infections

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

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

7. 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 cannulawith side
holes to permit withdrawal of fluid if end hole
is occluded by bowel/ Omentum

8. 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 bcozof presence of
collateral vessels
Surgical scars & visible veins should be
avoided.

10. Abd. Wall is thinner.
Pool of fluid is more.
Pt can be rolled easily to left for drainage.
WHY NOT RIGHT???
Appedicectomyscar, caecumfilled with gas in
pts taking lactulose.
Care must be taken not to injure inferior
epigasticartery which bleeds massively &
which is located near pubic tubercle

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

12. Anaesthetiseusing 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& Asciticfluid & minimisethe chance of
leakage.

14. With one hand pull the abdominal wall n with
other hand operate the syringe. Hand on the
abd.wallshould not be removed untillthe
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 lignocainesol.
Cont. the same procedure until the needle enters
fluid.

15. Aspiration should be intermittent not
continuous.
Cont. may pull the bowel or omentumonto
needle tip,occludingthe 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.
Fliudshould drip from the hub of the needle.
Larger the nick greater the post paracentesis
leak.

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

17. Small amount of fluid may be difficult to drain
bcozomentum/bowel may block the end of
needle. So multi hole needles are helpful.
Misconception of poor flow is LOCULATION.
True loculationis seen in peritoneal
carcinomatosiswith malignant adhesions or
bowel rupture with surgical peritonitis.
Loculationnever occur in cirrhosis or heart
failure with ascitesor SBP.

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

19. It is removal of >5 lit of fluid.
In refractory ascites,removalof as much fluid as
possible with sod.restricteddiet 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
bcozcough will prevent pain sensation.

21. Asciticfluid leak:
-improper Z track
-using large bore needle
-large skin nick
Rx: keep ostomybag over nick.
Bleeding:
-artery or vein
In inferior epigastricbleed fig. of 8 suture is
placed surrounding the needle site.

22. Rarely laprotomyis needed to control
bleeding in pts with renal failure n
hyperfibrinolysis.
Bowel perforation
Infections
Catheter residue broken into adb.wall.