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Paracentesis

A paracentesis procedure removes fluid from the peritoneal cavity. The procedure can be both diagnostic and therapeutic for the management of ascites. An abdominal paracentesis procedure can be performed with or without imaging depending on the amount of ascites present in the abdomen. When performed by most interventional radiologists, ultrasound guidance is commonly used for needle placement. From a technical standpoint, paracentesis is simple and straightforward in most settings. However, understanding the management of portal hypertension, options for treatment of ascites and post-procedural care for high-volume paracentesis can layer complexity to the medical care of patients with ascites. We lay out everything you need to know for a successful paracentesis procedure below, including: prep, indications, procedure steps, position, and complications.

Paracentesis Procedure Steps

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Ep 206 Improving Workflow Efficiency: Starting with Paracentesis with Dr. Karen Brown
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Paracentesis Pre-Procedure Prep

Paracentesis Indications

Diagnostic
• Sample fluid for spontaneous bacterial peritonitis (SBP)
• Evaluate ascites to determine causative factors
Therapeutic
• Relieve pressure

Often times, paracentesis is both diagnostic and therapeutic

Contraindications

• Acute abdomen
• Uncorrectable bleeding diathesis

Pre-Procedural 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

Paracentesis Podcasts

Listen to leading physicians discuss paracentesis on the BackTable VI Podcast. Get tips, tricks, and expert guidance from your peers and level up your practice.

Episode #206

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Dr. Karen Brown explains how she improved paracentesis workflow by creating a service that has shortened procedure time, decreased hospital length of stay, and improved patient and referring provider satisfaction.

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Episode #87

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Interventional Radiologist Rajeev Suri from UT Health San Antonio 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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Paracentesis Procedure Steps

Antibiotics

Not routinely recommended

Technique and Equipment

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

Paracentesis 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 position 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

Albumin For Paracentesis

• 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

Post-Procedure

Post-Procedural Care

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

Post Paracentesis Complications

• 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

• 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

References

[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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Improving Workflow Efficiency: Starting with Paracentesis with Dr. Karen Brown on the BackTable VI Podcast)
Deep Dive Into Ascites with Dr. Rajeev Suri on the BackTable VI Podcast)
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