Caput Medusa, it just sounds evil.

The Paracentesis:

I know this procedure wasn't taught in PA school so let's talk about it here:

First, some background. By definition, ascites is the accumulation of fluid within the peritoneal cavity.
In America, the most common cause is cirrhosis.
Diseases like cirrhosis can lead to portal hypertension, and this causes fluid to be diverted from the venous system to...well everywhere. Patients may present with: increased abdominal pain, shortness of breath, back pain, encephalopathy.

Paracentesis is a procedure to remove this fluid. This may be for diagnostic or therapeutic purposes.

Before you get started, make sure you check: PT, platelets, and H/H.

Clinical PEARL: What is the best test to assess the status of liver disease? PT!

Ultrasound is the wave of the future (get it?). It's being slowly incorporated into medical schools and PA programs, but it didn't make it to my school. For those in my situation, don't be afraid!: 1) roll the machine next to the patient 2) power on 3) select a probe and place gel or lube 4) place on patient.

X marks the spot

The diagram to the left gives a rough estimate to good locations to poke. Try and avoid the red lines, those are the inferior epigastric arteries.


Once the probe is on the patient, take a look:

© UC Regeants

The black space represents the ascitic fluid (water has a high impedence, reflecting most of it away) The white loops represents the bowel. The goal is to insert the needle through the abdominal wall and into the fluid space (not hitting the bowel is a good thing!) Mark the area you want to go in.

They say the left lower quadrant is easier to penetrate the abdominal wall, so give it a shot.

Also, have the patient pee. You don't want to poke a distended bladder.

CardinalHealth®

Equipment:
1) sterile gloves

2) betadine or chlorhexidine (Chloraprep®)

3) paracentesis kit
  a) 16g caldwell needle/spinal needle
  b) sterile drape
  c) 10cc syringe
  d) gauze
  e) thoracentesis tubing

4) evacuation bottles x 5
5) Lidocaine and all that jazz.

Contraindications:
1) unstable/uncooperative patient
2) abdominal wall cellulitis

Procedure:
- Preparation: Get a trash can nearby, have your kit open and ready. Have your evacuation bottles nearby, preferably on the ground.

- Place the patient sitting, semi-fowler's.
- Use sterile technique...'nuff said.
- Insert the catheter with 10cc syringe attached at a

45° angle: To reduce the complication of fluid leakage it is important to use the Z-track technique.

- There will be some resistance as you poke through the wall, once you poke through slowly draw back your syringe.
- Once you draw back fluid, you're in! Give yourself a mental high-five. Keep the fluid in the syringe, you can use it for labs.
- Remove the syringe from the catheter, and withdraw the needle from the catheter (refer to picture on the top of this post)
- attach tubing and viola!
- once all is done, pressure dressing and a band-aid.

It is recommended to stay < 5L for a therapeutic paracentesis. Remember that these patients have been accumulating fluid in their abdomen for months, taking out too much can result in a disruption in their fluid circulation and kidney function.

Once you get over the success of your paracentesis, remember to put in orders for peritoneal fluid analysis: gram stain, cell count, culture.

Baxter®

It would be wise to NOT send your patient home until labs are resulted to rule out any spontaneous bacterial peritonitis.

Monitor patient's vitals for hypotension. Consider albumin (25%), 25cc for every 2 L of ascitic fluid removed.

Sometimes patients with cirrhosis are managed with diuretics and sodium restriction. This is only effective if the serum ascites albumin gradient (SAAG) is >1.1.
Spironolactone 40mg qAM
Furosemide 100mg qAM

Clinical PEARL: Why can patients with ascites present with a right pleural effusion? Peritoneal fluid can pass through the diaphragmatic lymphatics which are larger on the right than left (diaphragmatic effect). Thus, patients may present with shortness of breath, and logic will dictate this is secondary to abdominal distension. It's a good thing you're a smart PA and order a CXR to rule-out hydrothorax!


If in the event you are out of paracentesis kits, the quick and dirty requires standard supplies:
1) 14g angiocatheter
2) local anesthetic
3) 10cc syringe
4) IV tubing
5) wash basin

The procedure is the same, but cut the IV tubing at your desired length and tape it to the wash basin. Insert the angiocatheter as you would the caldwell needle, attach to IV tubing and let it drain into the wash basin. Most wash basins are 5 quarts, so that roughly equal 4.7 L. Once the basin is full, you're done!

Leaking? All you need is some dermabond, nasal cannula, and tape.

Reference:
http://sfgh.medicine.ucsf.edu/education/resed/procedures/paracentesis/
http://note3.blogspot.com/2004/02/paracentesis-procedure-guide.html
http://sfgh.medicine.ucsf.edu/education/resed/procedures/paracentesis/pdf/Paracentesis.pdf

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