1. Diagnostic: A new diagnosis of ascites (either in outpatient or inpatient setting), suspected spontaneous bacterial peritonitis, usually each hospitalization of a patient with cirrhosis and ascites (as this is frequently associated with spontaneous bacterial peritonitis that is asymptomatic or causes only minor symptoms).
2. Therapeutic: Initial treatment of large ascites (one-time fluid evacuation), ascites refractory to diuretics (repeated paracentesis is necessary).
Disseminated intravascular coagulation or severe (symptomatic) bleeding disorder not responding to vitamin K and fresh-frozen plasma (FFP), acute abdominal conditions requiring urgent surgery. A high international normalized ratio (INR) or low platelet counts associated with liver cirrhosis are not an absolute contraindication to paracentesis, but the threshold where correction may be required is not known.
Hematoma of the abdominal wall (1%), infection of the ascites fluid, perforation of the bowel or urinary bladder, and hemoperitoneum (<1/1000 patients). In the case of therapeutic paracentesis, hypotension (caused by a blood volume shift to the decompressed visceral circulation), renal impairment, and electrolyte disturbances.
Obtain a patient’s informed consent. The patient should void prior to the procedure. It is mandatory to maintain good intravascular volume using infusion of crystalloid or colloid (albumin). In most patients with asymptomatic coagulopathy, the administration of FFP or platelet concentrate is not necessary. Place the patient in a semirecumbent position (with the trunk elevated).
Note: A standard dedicated paracentesis kit may be preferred in most situations, especially with large-volume paracentesis.
2. Catheter with a needle as for peripheral vein catheterization, bore 1.2 to 1.7 mm (18-16 gauge, 45 mm in length, allowing for fluid aspiration). A longer needle is necessary in patients with a thick abdominal wall (obesity or significant abdominal wall edema).
3. Three-way stopcock, drain tubing as for drip infusion, bottle for fluid collection (if not using a dedicated paracentesis kit).
4. Scalpel for skin incision if using a large-bore catheter.
Site of ParacentesisTop
Ultrasound guidance, when available, is preferred.
Percuss the abdominal wall to verify the fluid level. The optimal paracentesis site usually lies 2 to 3 cm below the umbilicus or at a third of the length of the lower line connecting the anterior superior iliac spine with the umbilicus on the left side, less frequently on the right side.
1. Prepare the surgical field (see Field Preparation for Small Procedures). Infiltrate the skin, subcutaneous tissue, and muscles down to the peritoneum using 1% or 2% lidocaine (see Local Infiltration Anesthesia).
2. Pull the skin taut down and insert a syringe with a needle while aspirating continuously until the peritoneum is penetrated and fluid outflow is confirmed. Advance the catheter over the needle (or alternatively introduce the catheter over a guidewire as in pericardiocentesis).
3. After diagnostic collection of 50 to 100 mL of fluid or therapeutic decompression, protect the puncture site with a sterile dressing.
After the ProcedureTop
Removal of larger amount of ascites may trigger a potentially harmful hemodynamic reaction (postparacentesis circulatory dysfunction), which is why volume replacement in such situations became a standard of practice. Our practice is to administer 6 to 8 g IV albumin in the form of a 20% to 25% solution for every liter of removed fluid over 4 to 5 L rather than using other volume expanders.Evidence 1Weak recommendation (benefits likely outweigh downsides, but the balance is close or uncertain; an alternative course of action may be better for some patients). Moderate Quality of Evidence (moderate confidence that we know true effects of the intervention). Quality of Evidence lowered due to imprecision (mortality) and indirectness (postparacentesis circulatory dysfunction). Bernardi M, Caraceni P, Navickis RJ, Wilkes MM. Albumin infusion in patients undergoing large-volume paracentesis: a meta-analysis of randomized trials. Hepatology. 2012 Apr;55(4):1172-81. doi: 10.1002/hep.24786. PubMed PMID: 22095893.