Paracentesis

Contraindications

Paracentesis if coagulopathic

• Coagulation studies are NOT required before performance of the procedure
  • Incidence of clinically significant bleeding complications is low even if in liver failure with an elevated INR (< 0.2%)
• No data supports cutoff values beyond which paracentesis should be avoided/prophylactically transfused
• Routine use of FFP and platelets is not recommended
• Procedure is contraindicated if the patient is actively bleeding or in DIC

Equipment Needed

• Lidocaine with epi
• Chlorhexidine
• Paracentesis kit (catheter, 11 blade, syringes, bandaid)
• Ultrasound
• Vacuumed bottles

Procedure

1. Use ultrasound to identify safe ascites pocket to drain
   • if no ultrasound available, can percuss to identify pocket
   • Try to pick site away from inferior epigastric artery
   • LLQ preferred over RLQ
   • Midline infraumbilicus is avascular (linea alba) but has lower success rate
2. Prep area
3. Anesthesize area with Lidocaine
4. Use needle to enter peritoneum, advance catheter upon withdrawing ascitic fluid
5. Attach cathether to vacuum bottles for therapeutic tap, Withdrawal with syringe for diagnostic tap

Pearls

• Placing culture in blood culture tube increases yield

Workup

• Cell count with dif
• Cx (BCx bottles)
• Grm stain

Consider:

• Albumin and SERUM albumin
• Protein
• Glucose
• LDH and SERUM LDH at same time
• Amylase

Specific circumstances:

• TB smear and Cx
• Cytology
• TG
• Billirubin

Diagnosis

SBP

Any:

• >500 WBC
• >250 PMNs
• Positive gm stain (single microbe)

^For bloody tap, subtract 1 WBC for every 250 RBC

Consider Peritonitis (eg. perf appy, chole)

Any:

• >10,000 WBC
• Polymicrobial gm stain
• Total protein >1g/dL
• Glu <50
• Increased LDH

If on Peritoneal Dialysis

SBP if:

• >100WBC OR >50% NEUT

If on Nightly APD

SBP if:

• >50%NEUT
• Amylase (>100 suggestive of intra-abdominal process)

See Also

• Spontaneous Bacterial Peritonitis (SBP)