Paracentesis
Indications
- Rule-out SBP
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
- Lidocaine with epi
- Chlorhexidine
- Paracentesis kit (catheter, 11 blade, syringes, bandaid)
- 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
- LLQ preferred over RLQ
- Midline infraumbilicus is avascular (linea alba) but has 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
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)