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Introduction

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Paracentesis is performed in the intensive care unit (ICU) for diagnostic or therapeutic purposes to drain free fluid from the peritoneum.

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Definitions and Terms

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  • ▪  Paracentesis: Aspiration of peritoneal fluid from the abdomen (Figure 45-1).
  • ▪  Peritoneal lavage: To be distinguished fromparacentesis—performed to evaluate abdomen for free bleeding typically following trauma—has been largely supplemented by ultrasound.

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Figure 45-1.
Graphic Jump Location

Graphic showing paracentesis aspiration of peritoneal fluid.

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Techniques

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  • ▪  Indications:
    • —Diagnostic:
      • • To determine the etiology of ascites.
      • • To diagnose infection in chronic ascites (ie, spontaneous bacterial peritonitis).
      • • To diagnose intra-abdominal malignancy.
    • —Therapeutic:
      • • To relieve respiratory distress due to ascites.
      • • To decrease intra-abdominal pressure and improve venous return.
  • ▪  Contraindications:
    • —Coagulopathy
    • —Acute abdominal process requiring surgical management
    • —Skin cellulitis over proposed incision site
    • —Distended bladder or bowel
    • —Previous abdominal surgery with adhesions
    • —Pregnancy
  • ▪  Ultrasound and/or physical examination (ie, presence of a fluid wave) can be used to diagnose presence and/or location of ascetic fluid.
  • ▪  Prior to the procedure, patient consent should be obtained, site should be prepped and draped, and universal protocol should be performed as per Section I.
  • ▪  The bladder and stomach should be emptied prior to performance of the procedure.
  • ▪  Technique:
    • —Patient should be positioned supine or in lateral decubitus position in order to bring free ascites below proposed insertion spot as determined by examination or ultrasound.
    • —Local anesthetic is infiltrated into skin over proposed paracentesis site, typically paramedian (Figure 45-2) in anterior axillary line or in midline below umbilicus.
    • —A needle or Angiocath is inserted into the abdomen and aspirated (Figures 45-3 and 45-4).
    • —When free ascites fluid is obtained, a wire may be introduced into needle or Angiocath according to Seldinger technique, and a catheter introduced over the wire for fluid drainage (Figures 45-5, 45-6, 45-7, 45-8, and 45-9).
    • —Samples of the fluid are sent for diagnostic studies as warranted.
  • ▪  Complications:
    • —Gastric or bowel perforation
    • —Peritonitis
    • —Post-paracentesis hypotension secondary to volume redistribution
    • —Intra-abdominal bleeding

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Figure 45-2.
Graphic Jump Location

Infiltration of local anesthetic in skin wall along anterior axillary line.

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Figure 45-3.
Graphic Jump Location

Needle introduction into abdominal wall.

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Figure 45-5.
Graphic Jump Location

Introduction of Seldinger exchange wire through needle into abdomen.

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