Paracentesis

Contraindications:

Absolute:
- Active skin infection at insertion site.
Relative:
- Severe coagulopathy.
Other Considerations:
- Caution if prior abdominal surgery (risk of adhesions).
- Loculated ascites may limit drainage.
- Avoid insertion through caput medusae.
- Avoid large-volume drainage in AKI or hemodynamic instability due to post-paracentesis circulatory dysfunction. Involve Gastroenterology/Hepatology if there are questions or concerns.

Risk of procedure:
- Bleeding
- Infection
- Intra-abdominal organ injury/perforation
- Renal dysfunction
- Persistent leakage at puncture site

Albumin consent (if anticipate removal of ≥4-5L):
- Albumin is a plasma-derived blood product. Risk of viral transmission is extremely low. Most reactions are mild/transient (hypotension, flushing, urticaria, nausea, fever).
- There is rare risk of severe allergic reactions such as anaphylaxis or severe hypotension.

Personal: Facemask, sterile gloves
Ultrasound: Obtain from Connell 3/9/10, Davies 4, or ER.
Procedure Equipment:
- Paracentesis kit and/or separate Angio catheter (based on preference)
- Chlorhexidine swabs (x3)
- 1% Lidocaine (without epinephrine), 10 mL syringe, 25-27G needle, blunt tip needle
- 50 ml syringes x2 (for fluid samples), 10 mL syringe (for infiltration)
- 4L drainage bag
- Tegaderm, sterile gauze, dressing

Confirm consent.
Position patient: Supine, head of bed elevated ~30°.
Use abdominal probe to identify fluid pocket (>4 cm) in RLQ, LLQ, or pelvis.
- Fan through area of interest in both longitudinal and transverse planes to ensure bowel/solid organs are not in trajectory.
- Tip: If difficulty obtaining an adequate pocket, optimize position by rotating into lateral decubitus or hip tilt with pillow.
- Note: Consider linear probe with colour doppler to exclude blood vessels directly below insertion site.
Identify insertion point and mark skin with blunt needle tip.
Recall probe angle and skin traction for needle insertion

Prep site with chlorhexidine swabs (x 3 swabs).
Open kit, set up sterile field, and drop in equipment.
1. Angio catheter, syringes, blunt needle, 25G needle, gauze, tegaderm.
Don sterile gloves, apply drapes to patient (i.e., triangulate method).
Draw lidocaine into 10 mL syringe.
Inject lidocaine under the skin, then deeper down the tract.
Wait 1-2 minutes for effect.

Attach Angio catheter to 10 ml syringe + insert into abdomen.
1. Ensure needle is inserted while aspirating back, matching ultrasound trajectory.
2. Hold and anchor needle on patient abdomen with non-dominant hand, and insert needle while simultaneously aspiration with dominant hand.
3. Pay careful attention to avoid kinking of the needle.
Advance catheter fully into the pocket. Confirm entry into peritoneum with aspiration of ascitic-fluid. Ensure fluid flows easily into the syringe.
Thread catheter into the abdomen, then withdraw needle. Plug catheter with finger to prevent leaking of fluid.
Collect diagnostic samples (50 mL syringes x2).
Connect catheter to drainage bag; secure catheter with Tegaderm to abdomen.
Once the desired volume is removed, remove catheter, apply gauze/dressing, dispose of sharps, and document procedure.

Indication: To prevent paracentesis induced circulatory dysfunction.
Replace with 6-8g of albumin per litre removed if greater than ≥4-5L.
- E.g., ~ 100mL of 25% albumin
Formulations:
- 25% albumin: 25 g/100 mL bottle.
- 5% albumin: 5 g/100 mL × 500 mL bottle = 25 g.

If bleeding: apply firm pressure dressing.
If persistent leakage: apply firm pressure dressing. Avoid ostomy bags due to infection risk.

Procedural steps written by: Zuhal Mohmand MD, Muralie Vignarajah MD

Staff Reviewed by: Dr. Kristel Leung (Gastroenterology-Hepatology)