Deborah DeWaay, MD Division of General Internal Medicine and Geriatrics

Hospital Medicine 2013

• Knowledge Residents should be able to: Explain the indications and contraindications for paracentesis Explain the risks and complications of paracentesis Explain the appropriate diagnostic testing for ascitic fluid Define the serum-ascites albumin gradient

Skills Residents should be able to: Use sterile techniques during the procedure Order and interpret the results of the ascitic fluid analysis

Attitudes: Residents should be able to: Identify the importance of using ultrasound to make paracentesis a

safer procedure

Objectives

Don’t hit the inferior epigastric artery Patients with coagulopathy from liver disease do not need

their INR corrected pre-procedure The risk of bleeding is not associated with coagulopathy

Key Messages

Evaluation for spontaneous bacterial peritonitis Signs/Sx: fever, abdominal pain, ttp on exam,

encephalopathy, AKI, unexplained acidosis, ↑WBC

Evaluation of new ascites Fluid should be analyzed to look for cause: portal HTN,

cancer, infection…

Surveillance paracentesis Look for asymptomatic SBP in a patient with know ascites

Large volume paracentesis Shouldn’t be first line: try diuretics first!

Indications

Disseminated intravascular coagulation disorder Problems with skin over the site Large veins, cellulitis, hematomas

Distended intra-abdominal organs Make the patient urinate before the procedure

Intra-abdominal adhesions or scars Bowel may be adhered to the peritoneum

Contraindications

Basic Anatomy

Inferior epigastric aa run along the rectus sheath

Postparacentesis circulatory dysfunction Persistent leakage of ascitic fluid Localized infection Abdominal wall hemorrhage Intra-abdominal wall hemorrhage (0.2%) Intra-abdominal organ injury Inferior epigastric artery puncture Bleeding risk is VERY low 0.19% with a death rate of 0.016% The risk of bleeding is not associated with coagulopathy!

Risks to procedure

Examine the abdomen for Surgical scars Engorged abdominal wall vessels Hepatomegaly Splenomegaly

Intestines will usually float out of the way unless there is adherence

Look Before You Poke

http://app.proceduresconsult.com/Learner/projects/FullDetails.aspx?ProcedureId=7&procSN=IM-012#

Ultrasound To Mark The Spot

Go 2cm below the umbilicus in the midline or 3 cm superior and medial to the anterior superior iliac spine

www.uptodate.com

Don’t Hit The Artery!!!

Procedure Anatomy

Mark the site Use sterile gloves Prep the site with chlorhexidine Apply a sterile drape Anesthetize the skin: make a wheal with 1% lidocaine with a 25

gauge syringe. Switch to a 22 gauge syringe and anesthetize deeper tissues. Alternate pulling back on plunger and injecting to avoid intravascular injection

Once into the peritoneum, inject extra lidocaine to anesthetize the peritoneum

5-10cc of lidocaine should be used

The Procedure

Make sure to use a scapel to nick the skin before inserting

the paracentesis needle Use the Z-tract method to help prevent leakage post

procedure Do not apply suction while advancing because this can

draw intestine to the needle

The Procedure

http://www.uptodate.com/contents/image?imageKey=GAST/76099&topicKey=GAST%2F16203&source=outline_link&search=paracentesis&utdPopup

=true

Diagnostic paracentesis: use a 60 cc syringe to withdraw fluid

Large volume paracentesis: insert tubing from the needle to the evacuation containers

Apply pressure to the site of puncture for several minutes A pressure dressing is sometimes helpful in patients with

recurrent ascites to prevent leaks Monitor patients with large volume paracentesis for

hemodynamic instability

Post-Procedure

Albumin and protein: tube without additives [Red top

tube] Cell count and differential: EDTA tube [Lavender] Culture [Use aerobic and anaerobic blood culture bottles] Gram stain [Sterile specimen cup] Cytology [Sterile specimen cup]

For MUSC per Lab Client Services

What Labs Should Be Ordered?

Post-paracentesis circulatory dysfunction Occurs after ≥ 5L of fluid taken off Give 8 gm of Albumin per L of fluid taken off

Persistant leaking Place a simple suture

Common Complications

Portal hypertension: cirrhosis (81%) There is a disruption of the hydrostatic-oncotic pressure

imbalance activation of the renin-angiotensin system sodium retention volume overload

Systemic volume overload – CHF (3%), AKI/CKD, Nephrotic syndrome

Exudative ascites – TB (2%), cancer (10%) Lymphatic obstruction - cancer

Ascites: Why?

SAAG = Serum albumin – Ascites albumin

SAAG < 1.1 Nephrotic sx: TP >2.5g/dL Peritoneal carcinomatosis: +

cytology Peritoneal TB Pancreatitis: ascitic amylase

>100, ascitic PMN > 250cells/mm3

Serositis

SAAG >1.1 CIRRHOSIS: TP <2.5g/dL Alcoholic hepatitis Massive hepatic mets CHF: TP ≥ 2.5g/dL Constrictive pericarditis Budd-Chiari syndrome Spontaneous bacterial

peritonitis: ascites PMN > 250cells/mm3

http://www.accessmedicine.com/videoPlayer.aspx?aid=51001

3108&searchStr=paracentesis Go to www.musc.edu/library Access medicine Harrison’s online video “Paracentesis”

http://app.proceduresconsult.com/Learner/projects/ChecklistDetails.aspx?ProcedureId=7&procSN=IM-012&Video=1# Go to www.musc.edu/library Clinical resources Procedures consult Search paracentesis

Helpful videos

1. Maria A. Yialamas, Anna Rutherford, and Lindsay King. Abdominal Paracentesis.

Harrison’s Online 2. http://app.proceduresconsult.com/Learner/projects/ChecklistDetails.aspx?Procedu

reId=7&procSN=IM-012&Video=1# 3. Runyon BA, Montano AA, Akriviadis EA, Antillon MR, Irving MA, McHutchison JG.

The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Ann Intern Med. 1992 Aug 1;117(3):215-20

4. Patel P, Ernst F, Gunnarsson C. Evaluation of hospital complications and costs associated with using ultrasound guidance during abdominal paracentesis procedures. J Med Econ. 2012; 15(1): 1-7

5. Thomsen TW, Shaffer RW, White B, Setnik GS: Paracentesis. N Engl J Med. 2006;355:e21

6. Sandhu BS, Sanyal AJ: Management of ascites in cirrhosis. Clin Liver Dis. 2005;9:715-732

7. Runyon BA, AASLD Practice Guidelines Committee. Management of adult patients with ascites due to cirrhosis: an update. Hepatology. 2009;49(6):2087

References