Therapeutic Paracentesis

Discuss therapeutic paracentesis?

  • Obtain informed consent prior to the procedure.
  • The procedure should be performed with strict sterile conditions.
  • Routine use of fresh-frozen plasma (FFP) or platelet concentrates is not recommended.
  • All ascitic fluid should be drained to dryness in a single session as rapidly as possible over 6-8 hours. The drain should not be left in overnight.
  • Plasma volume expansion should be given once paracentesis is complete.
  • Albumin (8 g albumin/ litre of ascites removed) should be used for volume expansion after large volume paracentesis (> 5 litres).
  • Paracentesis of <5 litre of uncomplicated ascites should be followed by plasma expansion with a synthetic plasma expander (150–200 ml of gelofusine or haemacel) and does not require volume expansion with albumin.
  • Diuretics should be reintroduced within 1-2 days after paracentesis at a usual dose of spironolactone 200mgs a day.

Discuss the indications for paracentesis?

Large volume paracentesis (> 5 litres) is performed in haemodynamically stable patients with tense or refractory ascites to alleviate discomfort or respiratory compromise. Serial large-volume paracenteses may be required in patients with refractory ascites or ascites that does not respond to diuretics.

Discuss the contraindications for paracentesis?

Disseminated intravascular coagulation.

Relative contraindications-

  • Pregnancy
  • Small bowel obstruction
  • Organomegaly
  • Intraabdominal adhesions

Many patients undergoing paracentesis will have baseline coagulopathy or thrombocytopenia. However, the incidence of clinically significant bleeding during paracentesis is extremely low, and routine use of FFP or platelet concentrates is not recommended. However, if thrombocytopenia is severe (40 000) most clinicians would give pooled platelets to reduce the risk of bleeding.

Explain the procedure?

Equipment- The cannula should have multiple side perforations; otherwise the end becomes blocked by bowel wall. (Bonanno Suprapubic catheter Kit is usually used).

Preparation

  • Explain the procedure to the patient and obtain informed consent.
  • You should discuss the risks of bleeding, infection, injury to intraabdominal organs, and post procedure hypotension.
  • Place the patient supine in the bed with his or her head slightly elevated. The procedure should be performed with strict sterile conditions.
  • Needle-insertion sites- right or left lower quadrant, 2 to 4 cm medial and cephalad to the anterior superior iliac spine.  You must insert the needle lateral to the rectus sheath to avoid puncturing the inferior epigastric artery.

Paracentesis

  • Use the Z technique to minimize the risk of an ascitic fluid leak after the procedure.
  • All ascitic fluid should be drained to dryness in a single session as rapidly as possible over 6-8 hours, assisted by gentle mobilization of the cannula or turning the patient on to their side if necessary.
  • The drain should not be left in overnight.

Post paracentesis

  • After paracentesis, the patient should lie on the opposite side for two hours minimize the risk of ascitic fluid leakage.
  • A synthetic plasma expander (150–200 ml of gelofusine or haemacel) is used if less than 5 litres.
  • Large volume paracentesis (> 5 L) should be performed in a single session with volume expansion being given once paracentesis is complete, preferably using 8 g albumin/ litre of ascites removed.

Discuss the complications of paracentesis?

  • Post-paracentesis circulatory dysfunction (PPCD) – this may lead to hypotension, hyponatremia, renal failure and shortened survival.
  • Haemoperitoneum
  • Intraabdominal organ injury
  • Inferior epigastric artery injury
  • Persistent ascitic fluid leakage
  • Localised infection
  • Abdominal wall haematomas

Discuss the role of diuretics post paracentesis?

Following paracentesis, ascites recurs in the majority (93%) if diuretic therapy is not reinstituted, but recurs in only 18% of patients treated with spironolactone.
Reintroduction of diuretics (usually spironolactone 200mgs a day) after paracentesis (usually within 1–2 days) does not appear to increase the risk of postparacentesis circulatory dysfunction.

Ref

  1. Moore KP, Aithal GP. Guidelines on the management of ascites in cirrhosis. Gut. 2006 Oct; 55 Suppl 6:vi1-vi12.
  2. Thomsen TW et al. Videos in clinical medicine. Paracentesis. N Engl J Med 2006;355(19):e21, 2006.
  3. Cabrera J, Inglada L, Quintero E, Jimenez W, Losada A, Mayor J, Guerra C. Large-volume paracentesis and intravenous saline: effects on the reninangiotensin system. Hepatology 1991; 14:1025-28.

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