View source for Paracentesis

==Indications==
[[File:Scheme body cavities-en.png|thumb|Lateral view showing abdominopelvic cavity.]]
[[File:Gray1036.png|thumb|Posterior view of the anterior abdominal wall in its lower half.]]
[[File:Hesselbach triangle 547.gif|thumb|View of Hesselbach's triangle from inside the abdomen showing the right inferior epigastric artery and vein arching superio-medially.]]
[[File:Gray399.png|thumb|Diagram of sheath of Rectus above the arcuate line.]]
[[File:Auscities.png|thumb|Ascites appearance on ultrasound]]
*Rule-out [[SBP]]
*Ascites analysis
*Clinical deterioration in a patient with ascites (e.g. fever, abdominal pain or tenderness, encephalopathy, acidosis, deterioration in renal function, peripheral leukocytosis)<ref>Runyon B. Diagnostic and therapeutic abdominal paracentesis. UpToDate. "Diagnostic and therapeutic abdominal paracentesis?" Published February 18, 2014. Accessed September 8, 2015.</ref>
*Therapeutic in patient with discomfort from tense ascites

==Contraindications==
{{Paracentesis if coagulopathic}}

==Equipment Needed==
*[[Lidocaine]] with epi
*[[Chlorhexidine]]
*Paracentesis kit (catheter, 11 blade, syringes, bandage)
*[[FAST exam|Abdominal bedside ultrasound]]
*Vacuumed bottles

==Procedure==
#Use ultrasound to identify safe ascites pocket to drain and mark the area of entry if possible
#*if no ultrasound available, can percuss to identify pocket
#*Try to pick site away from inferior epigastric artery
#*Prefered location is that with the greatest pocket, past history of success, and furthest distance from bowel<ref>Runyon BA. Paracentesis of ascitic fluid. A safe procedure. Arch Intern Med. 1986;146:2259-2261</ref>
#*Midline infraumbilicus is avascular (linea alba) but may have lower success rate
#Prep area
#Anesthesize area with Lidocaine
#Use needle to enter peritoneum, advance catheter upon withdrawing ascitic fluid
#Attach cathether to vacuum bottles for therapeutic tap, Withdrawal with syringe for diagnostic tap

===Albumin===
*Consider [[albumin]] infusion of 1.5gm/kg in cirrhotics with [[SBP]] or with renal insufficiency to reduces the risk of circulatory dysfunction and [[hepatorenal syndrome]]<ref>Kwok CS, Krupa L, Mahtani A, et al. Albumin Reduces Paracentesis-Induced Circulatory Dysfunction and Reduces Death and Renal Impairment among Patients with Cirrhosis and Infection: A Systematic Review and Meta-Analysis. Biomed Res Int. 2013; 2013: 295153.</ref>

===Pearls===
*Placing culture in blood culture tube increases yield
*Z-track method involves pulling skin downwards with one hand while inserting needle to create nonlinear track
**Theoretically reduces risk of ascitic leak

==Workup==
{{SBP workup}}

==Evaluation==
{{Diagnosis of SBP}}

{{Spontaneous versus secondary bacterial peritonitis}}

==Complications==
*Hemorrhage (0 to 0.93%)<ref>Scheer D, Secko M, Mehta N. ACEP Focus On: Ultrasound-Guided Paracentesis. http://www.acep.org/Education/Continuing-Medical-Education-(CME)/Focus-On/Focus-On--Ultrasound-Guided-Paracentesis. Published on November 1, 2012. Accessed on September 8, 2015.</ref>
*Abdominal wall hematoma
*Mesenteric hematoma
*Bladder or bowel perforation (6 out of 1000)
*Inferior epigastric aneurysm
*Vessel laceration (aorta, mesenteric artery, iliac artery)
*Hypotension
*Infection (0.58 to 0.63%)
*Persistent ascitic fluid leak (5%)
**May be minimized with Z-track method

==See Also==
*[[Ascites]]
*[[Spontaneous bacterial peritonitis]] (SBP)

==External Links==
*[http://www.acep.org/Education/Continuing-Medical-Education-(CME)/Focus-On/Focus-On--Ultrasound-Guided-Paracentesis/ Focus On: Ultrasound-Guided Paracentesis]
*[https://www.merckmanuals.com/professional/gastrointestinal-disorders/how-to-do-gastrointestinal-procedures/how-to-do-paracentesis?query=paracentesis| Merk Manual: How to do Paracentesis]

===Videos===
*NEJM (9:50) https://www.nejm.org/doi/full/10.1056/NEJMvcm062234

==References==
<references/>

[[Category:Procedures]]
[[Category:GI]]