Paracentesis: Difference between revisions
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==Equipment== | ==Indications== | ||
*Lidocaine with epi | *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, bandaid) | *Paracentesis kit (catheter, 11 blade, syringes, bandaid) | ||
* | *[[FAST exam|Abdominal bedside ultrasound]] | ||
*Vacuumed bottles | *Vacuumed bottles | ||
==Procedure== | ==Procedure== | ||
Placing | #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 | |||
#*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 | |||
===Pearls=== | |||
*Placing culture in blood culture tube increases yield | |||
*Consider albumin infusion in cirrhotics with SBP or with large volume paracentesis to reduces the risk of circulatory dysfunction<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> | |||
*Z-track method involves pulling skin downwards with one hand while inserting needle to create nonlinear track | |||
**Theoretically reduces risk of ascitic leak | |||
==Workup== | ==Workup== | ||
{{SBP workup}} | |||
Consider | ===Consider=== | ||
*Albumin and SERUM albumin | |||
*LDH and SERUM LDH at same time | |||
*Amylase | |||
Specific circumstances | ===Specific circumstances=== | ||
*TB smear and culture | |||
*Cytology | |||
*TG | |||
*Billirubin | |||
== | ==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== | ||
SBP | *[[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] | |||
== | ==References== | ||
<references/> | |||
[[Category:Procedures]] | [[Category:Procedures]] | ||
[[Category:GI]] | [[Category:GI]] | ||
Revision as of 21:39, 15 January 2021
Indications
- 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)[1]
- Therapeutic in patient with discomfort from tense ascites
Contraindications
Paracentesis if coagulopathic
- Coagulation studies are NOT required before performance of the procedure[2]
- Incidence of clinically significant bleeding complications is low even if in liver failure with an elevated INR (< 0.2%)[3]
- 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)
- Abdominal bedside ultrasound
- Vacuumed bottles
Procedure
- 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
- Prefered location is that with the greatest pocket, past history of success, and furthest distance from bowel[4]
- 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
Pearls
- Placing culture in blood culture tube increases yield
- Consider albumin infusion in cirrhotics with SBP or with large volume paracentesis to reduces the risk of circulatory dysfunction[5]
- 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 Work-Up of Ascitic Fluid via Paracentesis
- Cell count with differential
- Gram stain
- Culture (10cc in blood culture bottle)
- Glucose
- Protein
Consider
- Albumin and SERUM albumin
- LDH and SERUM LDH at same time
- Amylase
Specific circumstances
- TB smear and culture
- Cytology
- TG
- Billirubin
Consider
- Albumin and SERUM albumin
- LDH and SERUM LDH at same time
- Amylase
Specific circumstances
- TB smear and culture
- Cytology
- TG
- Billirubin
Evaluation
Diagnosis of SBP via Ascitic Fluid Analysis
Standard Evaluation
- Paracentesis results supporting a diagnosis of SBP:
- Absolute neutrophil count (PMNs) ≥250, pH <7.35, OR blood-ascites pH gradient >0.1[6]
- Bacteria on gram stain (single type)
- SAAG > 1.1
- Diagnostic of portal hypertension with 97% accuracy[7]
- SBP rarely develops in patients without portal hypertension
- Protein < 1, Glucose > 50 (otherwise concern for secondary bacterial peritonitis)
For bloody tap, subtract 1 WBC for every 250 RBC[8]
If on peritoneal dialysis
See Peritoneal dialysis-associated peritonitis
- Cell count >100/mm with >50% neutrophils most consistent with infection[9]
Spontaneous versus secondary bacterial peritonitis
- Importance of distinction
- Mortality of secondary bacterial peritonitis (eg. perforated appendicitis, cholecystitis) ~100% if treatment is only antibiotics without surgery
- Mortality of unnecessary surgery in patients with SBP ~80%
- Laboratory findings
- Secondary bacterial peritonitis strongly suggested by:
- Neutrocytic fluid (PMN ≥250) with two or more of the following:
- Total protein concentration >1 g/dL (10 g/L)
- Glucose concentration <50 mg/dL (2.8 mmol/L)
- LDH greater than upper limit of normal for serum
- Ascitic alk phos >240
- Gram stain
- Large numbers of different bacterial forms
- Neutrocytic fluid (PMN ≥250) with two or more of the following:
- Secondary bacterial peritonitis strongly suggested by:
- Imaging
- If evidence of secondary bacterial peritonitis obtain abdominal imaging
- If no evidence of free air or contrast extravasation then surgery is not indicated
- If evidence of secondary bacterial peritonitis obtain abdominal imaging
Complications
- Hemorrhage (0 to 0.93%)[10]
- 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
External Links
Focus On: Ultrasound-Guided Paracentesis
References
- ↑ Runyon B. Diagnostic and therapeutic abdominal paracentesis. UpToDate. "Diagnostic and therapeutic abdominal paracentesis?" Published February 18, 2014. Accessed September 8, 2015.
- ↑ Wilkerson, Annals of Emerg Med, 2009
- ↑ Thomsen TW. Paracentesis. N Engl J Med 2006; 355: e21
- ↑ Runyon BA. Paracentesis of ascitic fluid. A safe procedure. Arch Intern Med. 1986;146:2259-2261
- ↑ 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.
- ↑ Wilkerson R, Sinert, R. The Use of Paracentesis in the Assessment of the Patient With Ascites. Ann Emerg Med 2009, 54(3): 465-68.
- ↑ Runyon BA, Montano AA, Akriviadis EA, et al. The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Ann Intern Med 1992; 117:215.
- ↑ Hoefs JC "Increase in ascites white blood cell and protein concentrations during diuresis in patients with chronic liver disease."Hepatology. 1981;1(3):249. PMID 7286905
- ↑ ISPD GUIDELINES/RECOMMENDATIONS http://www.ispd.org/guidelines/articles/update/ispdperitonitis.pdf
- ↑ 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.