1 / 30

Paracentesis

Paracentesis. Deborah DeWaay MD Medical University of South Carolina April 25, 2013. Objectives. Knowledge Residents should be able to: Explain the indications and contraindications for paracentesis Explain the risks and complications of paracentesis

varen
Download Presentation

Paracentesis

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  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

More Related