Paracentesis: Difference between revisions

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==Diagnosis==
==Diagnosis==
===[[SBP]]===
{{Diagnosis of 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)===
===Consider Peritonitis (eg. perf appy, chole)===

Revision as of 08:21, 30 May 2015

Indications

  • Rule-out SBP
  • Asites analysis

Contraindications

Paracentesis if coagulopathic

  • Coagulation studies are NOT required before performance of the procedure[1]
    • Incidence of clinically significant bleeding complications is low even if in liver failure with an elevated INR (< 0.2%)[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

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

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 Cx
  • Cytology
  • TG
  • Billirubin

Diagnosis

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[3]
    • Bacteria on gram stain (single type)
    • SAAG > 1.1
      • Diagnostic of portal hypertension with 97% accuracy[4]
      • 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[5]

If on peritoneal dialysis

See Peritoneal dialysis-associated peritonitis

  • Cell count >100/mm with >50% neutrophils most consistent with infection[6]

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)

Complications

See Also

External Links

References

  1. Wilkerson, Annals of Emerg Med, 2009
  2. Thomsen TW. Paracentesis. N Engl J Med 2006; 355: e21
  3. Wilkerson R, Sinert, R. The Use of Paracentesis in the Assessment of the Patient With Ascites. Ann Emerg Med 2009, 54(3): 465-68.
  4. 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.
  5. 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
  6. ISPD GUIDELINES/RECOMMENDATIONS http://www.ispd.org/guidelines/articles/update/ispdperitonitis.pdf