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Ascitic drain insertion (therapeutic paracentesis)

­­Ideally ascitic procedures should be ultrasound guided

Indications for ascitic drain insertion (therapeutic paracentesis)

  • Refractory ascites secondary to portal hypertension (usually in liver cirrhosis)
  • Palliation in malignant ascites
  • Respiratory embarrassment (secondary to diaphragmatic ‘splinting’)

Equipment required for ascitic drain insertion (therapeutic paracentesis)

  • Ultrasound and ultrasound operator
  • Dressing trolley & sharps bin
  • Sterile field
    • Sterile dressing pack
    • Sterile gloves
    • 2% Chlorhexadine swabs
  • Analgesia
    • 10mls of 1% or 2% Lidocaine
    • Orange (25G) needle (x1)
    • Green (19G) needle (x1)
    • 10ml Syringe (x1)
  • 20ml Syringe (x1)
  • Scalpel
  • Cannula dressing (x2)
  • Paracentesis catheter (Safe-T-centesis®, Bonnano or similar 18G drain)
  • Urinary catheter bag (or similar)
  • Blood culture bottles
  • 20% Human Albumin Solution (HAS)

Contraindications to ascitic drain insertion (therapeutic paracentesis)

  • Local infection
    • Choose another site
  • Cautions – but not contraindications
    • Coagulopathy (INR>2.0)
      • Attempt to correct INR to <1.5 if possible.
    • Platelets<50
      • Thrombocytopenia and coagulopathy is often present in liver disease and though it is a caution, it not a contraindication to paracentesis or drainage
      • The incidence of clinically significant bleeding is low; routine FFP or platelets is not indicated
    • Pregnancy
    • Organomegaly
    • Obstruction/ileus
    • Distended bladder
    • Abdominal adhesions

Potential complications of ascitic drain insertion (therapeutic paracentesis)

  • Sepsis (including secondary bacterial peritonitis)
  • Perforation of viscus or vessels causing haemorrhage (abdominal wall haematoma has been reported in up to 2% in case series)
  • Intra-vascular volume depletion (hypotension) & renal impairment
  • Exacerbation of hepatic encephalopathy

Pre-procedure

  • Consent patient
    • Infection, bleeding, pain, failure, damage to surrounding structures (especially bowel perforation), leakage
  • Ultrasound to confirm fluid and insertion sight (see ascitic tap pages)
  • Set up sterile trolley

Procedure for ascitic drain insertion (therapeutic paracentesis)

  • Position the patient supine in the bed with their head resting on a pillow.
  • Select an appropriate point on the abdominal wall in the right or left lower quadrant, lateral to the rectus sheath. If a suitable site cannot be found with palpation and percussion consider using ultrasound to mark a spot.
  • Clean the site and surrounding area with 2% Chlorhexadine and apply a sterile drape.
  • Anaesthetise the skin with Lidocaine using the orange needle. Ensure you raise a large bleb as the drain perforating the skin will be the most painful part of the procedure.
  • Anaesthetise deeper tissues using the green needle, aspirating as you insert the needle to ensure you are not in a vessel before infiltrating with lidocaine. Use a maximum of 10mls of Lidocaine.
  • Take the Bonanno catheter and advance needle to tip of catheter, thus straightening it out
  • Insert the paracentesis catheter using a ‘Z’ track
    • Perforate the skin perpendicularly, and then advance obliquely in the sub-cutaneous tissue for 1-2cm before returning to a perpendicular position to puncture the peritoneal cavity.
  • Gradually advance the catheter into the peritoneal space.
  • Once you have inserted the catheter to the equivalent length of the green needle where fluid was first aspirated, start to pull the needle back slowly whilst advancing the catheter.
  • Do not pull the needle back too far as it is needed for stability, but equally do not push the needle too far into the peritoneal cavity.
  • Advance catheter to the hilt and completely remove needle.
  • Fix with two sterile cannula dressings.
  • Affix the drainage bag and leave on free drainage after obtaining the required samples.
    • Microbiology
      • Microscopy, culture & sensitivities (be explicit if yeast or mycobacterium suspected)
      • Culture in blood culture bottles inoculated at the bedside
    • Haematology
      • Automated WCC count (send EDTA sample)
    • Biochemistry
      • Albumin, Protein, LDH, Glucose
      • Remember to send a serum albumin, LDH and glucose at the same time (or at least from the same day).
      • Special tests: Fluid amylase, Triglycerides, Bilirubin
    • Cytology
  • Remove drain after 6 hours if cirrhosis
    • This is due to the high risk of peritonitis
    • Drains for malignant effusions can be left in for longer but the risk of peritonitis still exists

Post-procedure

  • Monitor Pulse, BP and Respirations
    • 15 minutes for 1 hour; 30 minutes for 1 hour; And hourly for 4 hours
  • Measure and record drain and urine output
  • Observe for signs of shock or acute haemorrhage
  • In patients with liver cirrhosis do not leave drain in for more than 6 hours
  • In patients with cirrhosis consider infusing human albumin solution for every litre drained – liaise with gastroenterology for advice if needed
    • In portal hypertensive ascites order 20% Human Albumin Solution from the blood bank. Generally 100mls should be infused for each 2000mls of ascites drained.
    • Volume replacement is not routinely required for malignant ascites unless the patient becomes hypotensive during drainage (but suggest 250ml colloid fluid challenge if required).Send fluid for urgent cell count, MC&S, LDH, protein and cytology
  • Send paired LDH and protein serum samples
  • Consider antibiotic cover if SBP is suspected
    • Refer to your trust policy
    • Co-amoxiclav and Tazocin are commonly used

In the event of failure

  • Stop procedure
  • Seek senior help
  • Re-review imaging and patient with a senior colleague to ensure presence of fluid
  • Consider further imaging or ascitic drain insertion in radiology

Top Tips for ascitic drain insertion (therapeutic paracentesis)

  • Inserting a Bonanno catheter requires a similar motion to cannula insertion, it is important not to advance the needle too far but you need to ensure the catheter is passing into the peritoneum without kinking.
  • A Bonanno catheter is actually a form of suprapubic catheter. When ascitic drains are inserted in the radiology department, they will use pigtail catheters
  • In patients with a thick abdominal wall a spinal needle can be used to infiltrate anaesthetic and check position.
  • If you aspirate blood when infiltrating an anaesthetic; stop, withdraw your needle, change position by 1-2cm and try again.
  • If your patient becomes more hypotensive whilst being drained then temporarily clamp the drain and infuse colloid fluid iv (e.g 20% Human Albumin Solution or Gelofusin®).

 

Bonanno catheter

A Bonanno catheter

Click here for medical student OSCE and PACES examples of ascitic fluid analysis

Common ascitic fluid result examples for medical students, finals, OSCEs and MRCP PACES

 

Click here to download free teaching notes on ascitic drain insertion (therapeutic paracentesis): Procedures – Ascitic drain insertion

Perfect revision for medical students, finals, OSCEs and MRCP PACES