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• Sample fluid for spontaneous bacterial peritonitis (SBP)
• Evaluate ascites to determine causative factors
• Relieve pressure
Often times, paracentesis is both diagnostic and therapeutic

• Acute abdomen
• Uncorrectable bleeding diathesis

Preprocedural workup:
• H&P
• Understand indication
• Labs not routinely recommended - considered a low bleeding risk procedure from SIR anticoagulation guidelines.
• Review imaging to evaluate extent and location of ascites

SIR Anticoagulation Guidelines
• INR: correct to within rage of ≤ 2.0–3.0
• Platelets: transfuse if < 20,000
For patients with chronic liver disease
• INR: not applicable
• Platelet count: > 20,000
• Fibrinogen > 100 mg/dL


Antibiotics: not routinely recommended

Few different techniques and numerous options from equipment perspective

Intermittent vs continuous ultrasound guidance
• Sometimes called static vs dynamic
• Difference is using ultrasound to mark site for paracentesis vs continuous US guidance

Procedure steps:
• Typically US used for imaging guidance
• Prep and drape site in usual sterile fashion
• Anesthetize skin and soft tissues with lidocaine
• Many operators avoid dermatotomy to reduce chance of ascites leakage after procedure
• Advance needle into ascites
• Connect to suction

Additional considerations:
• Skin entry angle - 45° angle may reduce ascites leakage
• Z-track technique: seat needle within soft tissue. Pull skin down to before advance needle into ascites. Creates "Z" pattern for needle tract through soft tissue and may reduce peritoneal leakage
• Often times, operator may need a short thrust of needle to pierce peritoneum. Slow advance can tent peritoneum which can be painful and may lesson the distance between underlying bowel and ascites
• According to American Association for the Study of Liver Diseases (AASLD), albumin infusion should be given at a rate of 6 to 8 grams per liter of fluid removed when >5 liters of ascites are drained
• Typically 25% concentration
• Example: If 10 L of ascites removed, would administer either 60 or 80 g of Albumin


Postprocedural care:
• Most commonly, can leave immediately after procedure
• Physicians differ on whether to obtain pre and post procedural vitals

• Uncommon - less than 1% of procedures
• Ascitic fluid leakage
• Local infection
• Bleeding: abdominal wall hematoma and intraperitoneal hemorrhage
• Intestinal perforation
• Post Paracentesis circulatory dysfunction (PCD) - can lead to hyponatremia, fluid reaccumulation, renal impairment and increased mortality

Related Procedures

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[1] Patel IJ, Rahim S, Davidson JC, et al. Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions-Part II: Recommendations: Endorsed by the Canadian Association for Interventional Radiology and the Cardiovascular and Interventional Radiological Society of Europe. J Vasc Interv Radiol. 2019;30(8):1168-1184.e1. doi:10.1016/j.jvir.2019.04.017
[2] Chehab MA, Thakor AS, Tulin-Silver S, et al. Adult and Pediatric Antibiotic Prophylaxis during Vascular and IR Procedures: A Society of Interventional Radiology Practice Parameter Update Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Association for Interventional Radiology. J Vasc Interv Radiol. 2018;29(11):1483-1501.e2. doi:10.1016/j.jvir.2018.06.007
[3] Lindsay AJ, Burton J, Ray CE Jr. Paracentesis-induced circulatory dysfunction: a primer for the interventional radiologist. Semin Intervent Radiol. 2014 Sep;31(3):276-8. doi: 10.1055/s-0034-1382799. PMID: 25177092; PMCID: PMC4140947.
[4] Bernardi M, Caraceni P, Navickis RJ, Wilkes MM. Albumin infusion in patients undergoing large-volume paracentesis: a meta-analysis of randomized trials. Hepatology. 2012 Apr;55(4):1172-81. doi: 10.1002/hep.24786. PMID: 22095893.
[5] De Gottardi A, Thévenot T, Spahr L, Morard I, Bresson-Hadni S, Torres F, Giostra E, Hadengue A. Risk of complications after abdominal paracentesis in cirrhotic patients: a prospective study. Clin Gastroenterol Hepatol. 2009 Aug;7(8):906-9. doi: 10.1016/j.cgh.2009.05.004. Epub 2009 May 15. PMID: 19447197.

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Deep Dive Into Ascites BackTable Podcast Guest Dr. Rajeev Suri

Dr. Rajeev Suri

Dr. Christopher Beck

Dr. Rajeev Suri tells us about his clinical approach to the high-volume ascites patient, including paracentesis technique and tips, albumin regimen, and discussing the need for TIPS in some patients.



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