Paracentesis

1. Paracentesis Deborah DeWaay MD Medical University of South Carolina April 25, 2013

2. Objectives • Knowledge • Residents should be able to: • Explain the indications and contraindications for paracentesis • Explain the risks and complications of paracentesis • Explain the appropriate diagnostic testing for ascitic fluid • Define the serum-ascites albumin gradient and its role in the evaluation of ascites

3. Objectives • Skills • Residents should be able to: • Use sterile techniques during the procedure • Order and interpret the results of the ascitic fluid analysis including cell count, differential, gram stain and culture, albumin (serum and ascites) • Attitudes: • Residents should be able to: • Identify the importance of using ultrasound to make paracentesis a safer procedure

4. Key Messages • Don’t hit the inferior epigastric artery • Patients with coagulopathy from liver disease do not need their INR corrected pre-procedure • The risk of bleeding is not associated with coagulopathy

5. Indications • Evaluation for spontaneous bacterial peritonitis • Signs/Sx: fever, abdominal pain, ttp on exam, encephalopathy, AKI, unexplained acidosis, ↑WBC • Evaluation of new ascites • Fluid should be analyzed to look for cause: portal HTN, cancer, infection… • Surveillance paracentesis • Look for asymptomatic SBP in a patient with know ascites • Large volume paracentesis • Shouldn’t be first line: try diuretics first!

6. Contraindications • Disseminated intravascular coagulation disorder • Problems with skin over the site • Large veins, cellulitis, hematomas • Distended intra-abdominal organs • Make the patient urinate before the procedure • Intra-abdominal adhesions or scars • Bowel may be adhered to the peritoneum

7. Basic Anatomy Inferior epigastric aa run along the rectus sheath

8. The Peritoneal Cavity • Extends from the diaphragm to the pelvic inlet • It is lined with the visceral and parietal peritoneum • In a healthy patient it is only a capillary layer of fluid

9. Consent • Risks to procedure • Postparacentesis circulatory dysfunction • Persistent leakage of ascitic fluid • Localized infection • Abdominal wall hemorrhage • Intra-abdominal wall hemorrhage (0.2%) • Intra-abdominal organ injury • Inferior epigastric artery puncture

10. Bleeding Risk • Bleeding risk is VERY low • 0.19% with a death rate of 0.016% • The risk of bleeding is not associated with coagulopathy!

11. Equipment • Get familiar with the pre-package kit available to you • See the checklist available with this presentation

12. Positioning • For RLQ or LLQ approach, position the patient supinely with the head slightly elevated • For midline infraumbilical approach, use the left lateral decubitus position

13. Look Before You Poke • Examine the abdomen for • Surgical scars • Engorged abdominal wall vessels • Hepatomegaly • Splenomegaly • Intestines will usually float out of the way unless there is adherence

14. Ultrasound To Mark The Spot http://app.proceduresconsult.com/Learner/projects/FullDetails.aspx?ProcedureId=7&procSN=IM-012#

15. Ultrasound Makes This Safer • Smaller amounts of ascites can be identified for tap • Organomegaly can be avoided • One study compared abdominal paracentesis procedures in their institution with and without ultrasound: • The indications for paracentesis were similar between the two groups. • The incidence of adverse events was lower in ultrasound-guided procedures includind post-paracentesis infection, hematoma, and seroma • Overall cost of hospitalization was less with u/s

16. Don’t Hit The Artery!!! Go 2cm below the umbilicus in the midline or 3 cm superior and medial to the anterior superior iliac spine www.uptodate.com

17. Procedure Anatomy

18. The Procedure • Mark the site • Use sterile gloves • Prep the site with chlorhexidine • Apply a sterile drape • Anesthetize the skin: make a wheal with 1% lidocaine with a 25 gauge syringe. Switch to a 22 gauge syringe and anesthetize deeper tissues. Alternate pulling back on plunger and injecting to avoid intravascular injection • Once into the peritoneum, inject extra lidocaine to anesthetize the peritoneum • 5-10cc of lidocaine should be used

19. The Procedure • Make sure to use a scapel to nick the skin before inserting the paracentesis needle • Use the Z-tract method to help prevent leakage post procedure • Do not apply suction while advancing because this can draw intestine to the needle

20. http://www.uptodate.com/contents/image?imageKey=GAST/76099&topicKey=GAST%2F16203&source=outline_link&search=paracentesis&utdPopup=truehttp://www.uptodate.com/contents/image?imageKey=GAST/76099&topicKey=GAST%2F16203&source=outline_link&search=paracentesis&utdPopup=true

21. The Procedure • If you are only doing a diagnostic paracentesis, use a 60 cc syringe to withdraw fluid • If you are doing a large volume paracentesis, insert tubing from the needle to the evacuation containers

22. Post-Procedure • Apply pressure to the site of puncture for several minutes • A pressure dressing is sometimes helpful in patients with recurrent ascites to prevent leaks • Monitor patients with large volume paracentesis for hemodynamic instability

23. What Labs Should Be Ordered? • Albumin and protein: tube without additives [Red top tube] • Cell count and differential: EDTA tube [Lavender] • Culture [Use aerobic and anaerobic blood culture bottles] • Gram stain [Sterile specimen cup] • Cytology [Sterile specimen cup] For MUSC per Lab Client Services

24. Common Complications • Post-paracentesis circulatory dysfunction • Occurs after ≥ 5L of fluid taken off • Give 8 gm of Albumin per L of fluid taken off • Persistant leaking • Place a simple suture

25. Ascites: Why? • Portal hypertension: cirrhosis (81%) • There is a disruption of the hydrostatic-oncotic pressure imbalance  activation of the renin-angiotensin system  sodium retention  volume overload • Systemic volume overload – CHF (3%), AKI/CKD, Nephrotic syndrome • Exudative ascites – TB (2%), cancer (10%) • Lymphatic obstruction - cancer

26. Calculate the SAAG SAAG = Serum albumin – Ascites albumin

27. SAAG < 1.1g/dL • Nephrotic sx: TP >2.5g/dL • Peritoneal carcinomatosis: + cytology • Peritoneal TB • Pancreatitis: ascitic amylase >100, ascitic PMN > 250cells/mm3 • Serositis

28. SAAG ≥ 1.1 • CIRRHOSIS: TP <2.5g/dL • Alcoholic hepatitis • Massive hepatic mets • CHF: TP ≥ 2.5g/dL • Constrictive pericarditis • Budd-Chiari syndrome • Spontaneous bacterial peritonitis: ascites PMN > 250cells/mm3

29. Helpful videos • http://www.accessmedicine.com/videoPlayer.aspx?aid=510013108&searchStr=paracentesis • Go to www.musc.edu/library • Access medicine • Harrison’s online video “Paracentesis” • http://app.proceduresconsult.com/Learner/projects/ChecklistDetails.aspx?ProcedureId=7&procSN=IM-012&Video=1# • Go to www.musc.edu/library • Clinical resources • Procedures consult • Search paracentesis

30. References • Maria A. Yialamas, Anna Rutherford, and Lindsay King. Abdominal Paracentesis. Harrison’s Online • http://app.proceduresconsult.com/Learner/projects/ChecklistDetails.aspx?ProcedureId=7&procSN=IM-012&Video=1# • Runyon BA, Montano AA, Akriviadis EA, Antillon MR, Irving MA, McHutchison JG. The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Ann Intern Med. 1992 Aug 1;117(3):215-20 • Patel P, Ernst F, Gunnarsson C. Evaluation of hospital complications and costs associated with using ultrasound guidance during abdominal paracentesis procedures. J Med Econ. 2012; 15(1): 1-7 • Thomsen TW, Shaffer RW, White B, Setnik GS: Paracentesis. N Engl J Med. 2006;355:e21 • Sandhu BS, Sanyal AJ: Management of ascites in cirrhosis. Clin Liver Dis. 2005;9:715-732 • Runyon BA, AASLD Practice Guidelines Committee. Management of adult patients with ascites due to cirrhosis: an update. Hepatology. 2009;49(6):2087