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Accidente/incidente paracenteză

Generalități
Paracenteza reprezinta procedura medicala prin care se dreneaza fluid patologic din cavitatea
abdominala. Acumularea de lichid in cavitatea abdominala se numeste ascita si poate sa apara in
nenumarate situatii, printre care: ciroza hepatica, insuficienta cardiaca congestiva, boli
endocrine, sindrom nefrotic, malnutritie, neoplasme, infectii.
Paracenteza terapeutica este indicata in momentul in care lichidul de ascita s-a acumulat in
cantitate foarte mare si compromite functia respiratorie, determina dureri abdominale intense sau
agraveaza eventuale hernii ombilicale sau inghinale prezente la pacientul in cauza (se creste
semnificativ riscul de incarcerare si strangulare al acestora).
Medicul trebuie sa acorde atentie speciala zonei de punctie deoarece trebuie sa evite vasele
sangvine si intestinul. Miscarea se executa lent, fiind evitate miscarile bruste si punctia adanca.
Dupa ce vine lichid, acul se va fixa in acea pozitie, nu se va mai avansa, pentru a se evita
penetrarea intestinului.
Cantitatea scoasa variaza, insa in general este de maxim 4 litri. Daca se depaseste, pacientul
trebuie sa primeasca lichide pe cale perfuzabila. O astfel de masura este menita sa previna
instalarea hipotensiunii arteriale si chiar a socului

Diagnostic Criteria of Refractory Ascites

1) Lack of response to maximal doses of diuretic for at least 1 week

2) Diuretic-induced complications in the absence of other precipitating factors

3) Early recurrence of ascites within 4 weeks of fluid mobilization

4) Persistent ascites despite sodium restriction

5) Mean weight loss < 0.8 kg over 4 days

6) Urinary sodium excretion less than sodium intake

Cause
 Transudate (<30g/L protein) (Systemic disease)
Liver (Cirrhosis)
Cardiac e.g. RHF, CCF, SBE right heart valve disease and constrictive
Pericarditis
 Renal failure
 Hypoalbuminaemia (nephrosis)
 Exudate (>30g/L protein) (Local disease)
 Malignancy
 Venous obstruction e.g. Budd-Chiari, Schistosomiasis
 Pancreatitis
 Lymphatic obstruction
 Infection (especially TB)
Home | Investigations [tests] | Peritoneal Fluid Analysis

Peritoneal Fluid Analysis


Peritoneal fluid (ascitic fluid) analysis
 The peritoneum is a tough semi-permeable membrane lining abdominal and visceral cavities. it
encloses, supports and lubricates organs within the cavity. Paracentesis is effectively the
analysis of ‘Ascites’ – the abnormal accumulation of fluid within the abdomen.
 The peritoneum is important in osmoregulation
 Passive diffusion of water and solute (up to a certain size)
 Maintains osmotic and chemical equilibrium with blood and lymph
 Ascitesdevelops either from:
 Increased accumulation
 Increased capillary permeability
 Increased venous pressure
 Decreased protein (oncotic pressure)
 Decreased clearance
 Increased lymphatic obstruction
Cause
 Transudate (<30g/L protein) (Systemic disease)
 Liver (Cirrhosis)
 Cardiac e.g. RHF, CCF, SBE right heart valve disease and constrictive Pericarditis
 Renal failure
 Hypoalbuminaemia (nephrosis)
 Exudate (>30g/L protein) (Local disease)
 Malignancy
 Venous obstruction e.g. Budd-Chiari, Schistosomiasis
 Pancreatitis
 Lymphatic obstruction
 Infection (especially TB)
Analysate interpretation

Gross appearance
 Clear to pale yellow  Normal

 Milk-coloured (Chylous)  Malignant tumour, lymphoma, TB

 Parasitic infection, hepatic cirrhosis


 Cloudy/turbid  Peritonitis, Primary bacterial infection

 Perforated bowel, appendicitis, pancreatitis

 Strangulated or infarcted bowel

 Bloody tap  Benign or malignant tumour

 Haemorrhagic pancreatitis, perforated ulcer

Paracentesis biochemistry
Levels Interpretation

 Triglyceride  Elevated  Malignant tumour, lymphoma, TB

 Parasitic infection, hepatic cirrhosis

 Protein  0.3-4.0g/dL  Normal

 >4g/dL  TB, SBP

 Glucose  7-10  Normal

 <6  TB and malignancy

 Amylase  50% of serum level  Normal

 Increased (Up to 5x  Pancreatitis, pancreatic pseudocyst,

serum level pancreatic trauma or Intestinal

strangulation

 Alkaline phosphatase  Increased  Small bowel perforation and

strangulation

Exudate Serum:Ascites Ratios


 Evidence for these ascites:serum ratios is controversial
 Ascitic fluid protein/Serum Protein >0.5
 Ascitic Fluid LDH/Serum LDH >0.6
 Ascitic Fluid LDH >400
 Presence of any 2 of these three findings is usually associated with TB, Malignancy
or Pancreatitis
 Absence of all three usually indicates hepatic cause
The Serum-Ascites Albumin Gradient (SAAG)
 The SAAG has become more favored in helping to characterize ascites fluid
 The concept surrounds oncotic-hydrostatic balance
 Simple calculation:
 Serum albumin – Ascites albumin= SAAG
SAAG > 1.1 mg/dl SAAG < 1.1 mg/d

 Cirrhosis  Peritoneal Carcinomatosis

 Alcoholic Hepatitis  Tuberculous Peritonitis

 Cardiac Ascites  Pancreatic Ascites

 “Mixed Ascites”  Bowel Obstruction

 Massive Liver Metastasis  Biliary Ascites

 Fulminant Hepatic Failure  Nephrotic Syndrome

 Budd-Chiari Syndrome  Posteroperative Lymphatic Leak

 Portal Vein Thrombosis  Serositis in Connective Tissue Disease

 Veno-Occlusive Disease

 Myxedema

 Fatty Liver of Pregnancy

Microscopy and analysis

Red cell count Interpretation

 None  Normal

 >100/microlitre  Malignancy, TB

 >100,000/microlitre  Intra-abdominal trauma (DPL)

White cell count Interpretation

 <300/microlitre  Normal

 >300/microlitre  Abnormal

 >25% neutrophils  SBP (90%), cirrhosis (50%)

 >25% lymphocytes  TB or Chylous Ascites

 Mesothelial cells  TB peritonitis

 Gram +ve cocci  Primary peritonitis

 Gram –ve  Secondary peritonitis


Repeat Large-Volume Paracentesis Versus Tunneled Peritoneal Catheter
Placement for Malignant Ascites: A Cost-Minimization Study

OBJECTIVE. The objective of this study was to determine the point in time at which tunneled
peritoneal catheter placement becomes less costly than repeat large-volume paracentesis (LVP) for
patients with malignant ascites.

MATERIALS AND METHODS. Procedure costs were based on 2013 Medicare reimbursement rates.
Rates for specific complications were obtained from the literature and were assigned costs. A
decision tree–based Markov chain Monte Carlo model was designed with 11 cycles of 10 days, to
simulate 4000 subjects per trial. Patients were grouped according to initial treatment decision (LVP
vs catheter placement), and the total cost at the end of each 10-day cycle was calculated. The point
at which catheter placement became less costly than LVP was determined. Additional simulations
were used for bivariate analyses of all cost and probability variables and for trivariate analysis of
cycle length and volume of fluid drained per cycle.

RESULTS. Individual input probabilities were not significantly different from corresponding
simulation outcomes (p value range, 0.068–0.95). When complications were included in the model,
the cost curves crossed at a mean (± SD) of 82.8 ± 3.6 days (range, 75.8–89.6 days), corresponding to
a time between the performance of the ninth and 10th LVP procedures. Intersection occurred earlier
in simulations with a shorter cycle length and less fluid per cycle, but it was minimally affected by
changing individual complication probabilities and costs.

CONCLUSION. For patients with malignant ascites, LVP becomes more costly once the procedure is
performed nine or 10 times or at approximately 83 days, if paracentesis is repeated every 10 days,
with 5 L of fluid removed each time. Use of a tunneled peritoneal catheter improves the cost
advantage for patients who receive LVP more frequently or patients who have less than 5 L of fluid
drained per procedure.

Clinical Question

Does the performance of diagnostic paracentesis on patients admitted to


the hospital with cirrhosis and ascites effect in-hospital mortality.
Outcomes

Primary: In-hospital mortality length of stay, and total hospitalization cost


Secondary: length of stay (LC), and total hospitalization cost (HC)
Design

Retrospective Chart Review


Primary Results

 Out of 8,023,590 admissions in the 2011 NIS, 31,614 met inclusion


criteria
 51% underwent paracentesis

Critical Findings

 In-Hospital Mortality (Primary Outcome)


o Patients who did not undergo paracentesis had higher
mortality than those who did
o 8.9% vs 6.3% OR 1.83 (95% CI 1.66-2.02)

 Secondary Outcomes
o Early paracentesis (Day 0-1) showed a trend towards reduction
in mortality (5.5% vs 7.5%) that did not reach significance
o Among those diagnosed with SBP, early paracentesis was
associated decreased LOS (7.55 vs 11.45 days, P < 0.001) and
decreased HC ($61 624 vs $107 484, P < 0.001).

If you admit a patient with cirrhosis and ascites, perform a diagnostic


paracentesis.
COLLOID REPLACEMENT One controversial issue regarding therapeutic paracentesis is that of colloid
replacement. In one study, 105 patients with tense ascites were randomized to receive albumin (10
g/L of fluid removed) versus no albumin, after therapeutic paracentesis.91 Refractoriness to diuretic
treatment was not a prerequisite for entry into this study; in fact, 31.4% of patients had not received
diuretics.91 The group that received no albumin developed statistically significantly more (although
asymptomatic) changes in electrolytes, plasma renin, and serum creatinine than the albumin group,
but no more clinical morbidity or mortality.91 Although another study has documented that the
subset of patients who develop a rise in plasma renin after total paracentesis have decreased life
expectancy, there has been no single study large enough to demonstrate decreased survival in
patients given no plasma expander compared to patients given albumin after paracentesis.92
Multiple other randomized trials have been conducted. A meta-analysis of 17 trials involving 1225
patients has been published, demonstating a reduction in mortality with an odds ratio of death of
0.64 (95% CI, 0.41-0.98) in the albumin group.93 Albumin was shown to be superior to other plasma
expanders; the mean volume of ascitic fluid removed was 5.5-15.9 liters.93 Studies have infused
between 5 and 10 g of albumin per liter of fluid removed; 6-8 g/L have been the most common
doses.91-93 One study has compared albumin doses in 70 patients; the 4g/L group had similar
paracentesis-induced circulatory dysfunction and renal impairment to the 8g/L group.94

TREATMENT OPTIONS FOR PATIENTS WITH CIRRHOSIS AND ASCITES

First-Line Cessation of alcohol use, when present Sodium restricted diet and diet education Dual
diuretics, usually spironolactone and furosemide, orally with single daily dosing Discontinue non-
steroidal anti-inflammatory drugs Evaluation for liver transplantation
Second-Line Discontinue beta blockers, angiotensin converting enzyme inhibitors, and angiotensin
receptor blockers Consider adding midodrine especially in the profoundly hypotensive patient Serial
therapeutic paracenteses Evaluation for liver transplantation Transjugular intrahepatic portasystemic
stent-shunt (TIPS)

Third-Line Peritoneovenous shunt

Abstract
Introduction. Large volume paracentesis is considered a safe procedure carrying
minimal risk of complications and rarely causing morbidity or mortality. The most
common complications of the procedure are ascitic fluid leakage, hemorrhage, infection,
and perforation. The purpose of this study was to evaluate all hemorrhagic complications
and their outcomes and to identify any common variables. Methods. A literature search
for all reported hemorrhagic complications following paracentesis was conducted. A
total of 61 patients were identified. Data of interest were extracted and analyzed. The
primary outcome of the study was 30-day mortality, with secondary endpoints being
achievement of hemostasis after intervention and mortality based on type of
intervention. Results. 90% of the patients undergoing paracentesis had underlying
cirrhosis. Three types of hemorrhagic complications were identified: abdominal wall
hematomas (52%), hemoperitoneum (41%), and pseudoaneurysm (7%). Forty percent
of the patients underwent either a surgical (35%) or an IR guided intervention (65%).
Patients undergoing a surgical intervention had a significantly higher rate of mortality
at day 30 compared to those undergoing IR intervention. Conclusion. Abdominal wall
hematomas and hemoperitoneum are the most common hemorrhagic complications of
paracentesis. Transcatheter coiling and embolization appear to be superior to both open
and laparoscopic surgery in treatment of these complications.

1. Introduction
Abdominal paracentesis is a routine diagnostic and therapeutic procedure in patients
with ascites [1]. Large volume paracentesis (LVP) involves removal of as much ascitic
fluid as possible to relieve symptoms of a tense abdomen and dyspnea. Randomized
controlled trials have shown that LVP is safer and more effective than therapy with
diuretics for the treatment of tense ascites [2, 3]. Patients treated with LVP supported
by plasma volume expansion have shortened hospitalization, better-preserved systemic
hemodynamics, and renal function. Additional benefits include improvement in hepatic
hemodynamics, decreased risk of developing spontaneous bacterial peritonitis, and less
frequent hepatic encephalopathy. Thus, considerable evidence favors the use of LVP
with albumin replacement as the preferred treatment of tense ascites [4].
LVP carries risk of complications. Studies have reported leakage of ascitic fluid,
infection, bleeding, and bowel perforation following paracentesis. Mortality related to
the procedure is rare but has been documented. Data has varied on the incidence of
complications. Hemorrhagic complications of paracentesis are perhaps one of the most
common immediate and late complications which are associated with morbidity and
mortality. This group of complications has been conveniently attributed to the presence
of coagulopathy and/or thrombocytopenia. Two large-scale studies have reported very
low incidence of complication with LVP despite thrombocytopenia (mean platelet count
of 50.4 × 103/μL) and coagulopathy (mean INR of 1.7 ± 0.46) [2, 4, 5]. On the other
hand, there are multiple case reports and series of hemorrhagic and nonhemorrhagic
complications of LVP published in the literature contradicting the results of other larger
scale studies.
Practice guidelines from various societies such as the American Association for the
Study of Liver Diseases (AASLD), the International Ascites Club, and the European
Association for the Study of the Liver (EASL) do not consider paracentesis to be
unsafe in the presence of marked thrombocytopenia or prolongation in the
prothrombin time nor recommend correction of these parameters prior to paracentesis
Information on the etiology of cirrhosis was available in 38 out of 54 subjects (70%).
The most common cause of cirrhosis was alcoholic, noted in 19 out of 38 subjects (50%).
The etiology of ascites in the 6 noncirrhotic patients was tuberculosis, malignancy, acute
liver failure (2 subjects), acute respiratory distress syndrome complicated with pleural
effusion and ascites, and congestive heart failure.
Data on coagulopathy (defined as INR > 2), marked thrombocytopenia (defined as
platelet count less than 50,000/μL), and renal insufficiency (defined as GFR < 60 or
creatinine > 1.2) were available in 46/61 (75%) patients, 36/61 (59%) patients, and 17/61
(27%) patients, respectively. 59% of patients had coagulopathy, 8% had marked
thrombocytopenia, and 70% had some degree of renal insufficiency.
The type of hemorrhagic event was specified in 60 out of 61 patients (98%). Abdominal
wall hematomas were most common hemorrhagic complication (52%), followed by
hemoperitoneum in 41% and pseudoaneurysm in 7%.
46 out of 61 (75%) subjects received blood and blood products for severe hemorrhagic
complications, 13 (21%) cases did not require blood transfusion, and one subject (4%)
died due to severe hemorrhage before any intervention could be initiated.
24 out of 61 (40%) patients underwent a surgical or transcatheter intervention and 37
(60%) were managed conservatively. Type of intervention is summarized in Table 3.
An attempt to identify the source of bleeding was made in 29 (47.5%) subjects; four of
them were found after death. Close to 60% of the bleedings originated from inferior
epigastric artery or one of its tributaries

Hemorrhagic complications of paracentesis can be broadly placed into 3 groups:


abdominal wall hematoma, pseudoaneurysm, and hemoperitoneum. Our review
demonstrated that abdominal wall hematoma is the most frequent hemorrhagic
complication. Along with pseudoaneurysms of the inferior epigastric artery they
constitute two-thirds of all hemorrhagic complications. Hemoperitoneum, which is
usually the result of injury to a mesenteric varix, is responsible for close to one-third of
these complications.
Serious hemorrhagic complications of paracentesis are seen both with large volume
paracentesis and even with diagnostic paracentesis [16]. We did not have sufficient data
to compare these groups.
Mallory and Schaefer [11] evaluated 242 consecutive diagnostic abdominal
paracenteses in patients with liver disease and reported 4 patients with serious
hemorrhagic complication (1.7%) which was significantly higher than previously
published data. At that time they concluded that their higher complication rate could be
related to selection bias and a “sicker” patient population.
Runyon [1] prospectively evaluated 229 abdominal paracenteses and reported one major
complication (transfusion-requiring abdominal wall hematoma) (0.8%) and two minor
complications (non-transfusion-requiring hematomas) (1.6%). They therefore
concluded paracentesis to be a very safe procedure. However, the one patient who
required blood transfusion sustained a variceal hemorrhage and succumbed to that.
Although this does not appear to be directly related to the paracentesis, it demonstrates
that “major bleeding” occurs in patients who are in a more advanced stage of their liver
disease and their prognosis remains guarded regardless of the intervention performed.
In 1990, McVay and Toy [12] reviewed 608 procedures in 395 patients. The main goal
of their study was to determine if untreated mild to moderate coagulopathy results in
higher rates of hemorrhagic complications and if prophylactic plasma infusion affects
the rate of hemorrhagic complication. The incidence of significant bleeding defined as
more than 2-gram drop in Hgb was 3.1%, which was similar across different levels of
coagulopathy. Among the patients with significant bleeding, only one patient required
RBC transfusion (0.3%). The authors pointed out that they might have underestimated
minor bleeding, since volume shifts after paracentesis can mask minor drop in Hgb.
They concluded that for mild-moderate coagulopathy reversal of the coagulopathy is not
indicated.
De Gottardi et al. in their prospective trial noticed higher rates of complications in
patients with a higher Child-Pugh score [5]. Pache and Bilodeau noticed a similar trend
in patients with a higher MELD and Child-Pugh score [20]. They also noticed a
correlation between risk of hemorrhage and renal dysfunction rather than coagulopathy
and thrombocytopenia. In our review renal dysfunction was also seen as the most
prevalent metabolic derangement occurring in 70% of patients with bleeding, compared
to coagulopathy and thrombocytopenia (59% and 8%, resp.). We did not observe a
difference in frequency of these derangements among the subjects who survived or did
not survive a hemorrhagic complication.

Abstract

Background
Large volume paracentesis is found to be safer and more effective for the treatment of tense
ascites compared with larger-than-usual doses of diuretics according to studies. The
objectives of the study was to evaluate patients with refractory ascites regarding clinical
profile, technique of paracentesis, complications, amount of ascites drained, prognosis and co-
morbid conditions associated with it.

Methods
Retrospective study was performed including patients between January 2011 and December
2013 with data pooled from total of five hospitals. A total of 4,389 paracenteses were
performed on the 1,218 patients with a mean volume of 4,900 ± 2,795 mL ascitic fluid
drained. Blind technique, ultrasound-guided technique of paracentesis and pig tail catheter
drainage were evaluated. Diabetes mellitus data from available patients and data regarding co-
morbidities were analyzed. Coagulation abnormalities in patients were studied.

Results
Study group age ranged from 34 to 79 years, and alcohol is the main cause of cirrhosis.
Dyslipidemia was observed in 1,080 patients (88.66%). At the time of inclusion in the study,
40% of the patients had ≥ 2 other cirrhosis-related complications and 20% of the study
population had ≥ 3 complications. Early complications occurred in 27.5% (337) of patients
and late complications constituted 16.83% (205 patients).

Conclusions
Even with abnormal coagulation, paracentesis is a safe procedure. But significant co-
morbidities should be addressed with care in cirrhosis patients. Ultrasound guidance during
the procedure whenever required should be encouraged.
Aim of the study
The aim of the study was as follows: 1) evaluate the complications arising from large volume
paracentesis; 2) impact of the choice of needle type and usage of ultrasound in paracentesis;
3) amount of drained ascitic fluid and its role in complications; 4) prognosis of the patients
who underwent the procedure.
The primary endpoint was occurrence of complications classified as: 1) early or immediate
complications including ascitic fluid leak from the puncture site, local bleeding, technical
problems (e.g., need for repuncture, slipping of the catheter from the abdominal wall,
incomplete procedure) or complications requiring hospitalization within 7 days after the
procedure; 2) other serious complications included hepatorenal syndrome (HRS), hepatic
encephalopathy, spontaneous bacterial peritonitis (SBP) and large hematomas. The diagnosis
of confirmed SBP requires an elevated ascitic fluid absolute polymorphonuclear leukocyte
(PMN) count of at least 250 cells/mm3 (0.25 × 109/L) and a positive ascitic fluid bacterial
culture without an obvious intra-abdominal source of infection. SBP is considered if it
occurred within 30 days of procedure.
Discussion
Paracentesis is a word derived from Greek κεντάω (“to pierce”), a common procedure done in
outpatient department and medical wards. According to recent studies mild hematological
abnormalities do not increase risk of bleeding significantly [12, 13]. Risk of bleeding
increases with the following [14]: 1) prothrombin time > 21 s; 2) international normalized
ratio (INR) > 1.6 and 3) platelet count < 50,000/mm3. Acute abdomen requiring surgery is an
absolute contraindication. Relative contraindications are pregnancy, distended urinary
bladder, abdominal wall cellulitis, distended bowel and intra-abdominal adhesions [15].
Intravenous albumin infusions have been shown in recent studies to reduce the rate of
complications by preventing post-paracentesis-induced circulatory dysfunction (PICD). In
spite of the benefits, still procedure is associated with many complications [16].
Complications found in this study were similar to other retrospective and prospective studies,
even though few complications were minimal such as bleeding, slippage of catheter were less
common [17, 18].
Late and serious complications associated with paracentesis were hepatorenal syndrome,
hepatopulmonary syndrome, spontaneous bacterial peritonitis and hepatic encephalopathy.
These complications were observed but uncommonly in the study.
Higher incidence of complications with pig tail catheter compared to intravenous catheter
drainage of ascitic fluid was observed. This observation is reinforced by other studies in 2001
by Schlottmann et al and Shaheen and Grimm, which found a significantly lower rate of re-
punctures (1:6, P = 0.046) when using a special paracentesis needle [19, 20]. But the mean
ascitic fluid was 250 mL more drained through pig tail catheter compared to intravenous
catheter needle. The high incidence of complications in the pig tail catheter group may be due
to excess and rapid drainage.
We found that ultrasound-guided ascitic tap is safer than blind procedure and using pig tail
catheter. Using paracentesis needle is also accounted for the benefit in the patients who have
undergone ultrasound-guided ascitic fluid drainage. Ultrasound-guided paracentesis is
particularly useful with minimal-to-moderate ascites, access is difficult and complications
were expected due to drainage of the ascitic fluid described by Gottardi et al [21]. Few cases
are reported regarding deaths due to intra-peritoneal hemorrhage due to paracentesis even
under ultrasound guidance.
Our study found these significant observations. 1) Paracentesis is a relatively safe procedure
with low complication rate. 2) Ultrasound-guided paracentesis was observed to have low
complication rate even though blind paracentesis procedure is relatively safe with less
complications. 3) No deaths were observed during and up to 1 month of paracentesis
procedure attributable to the procedure. 4) Even though around 50% of patients had aberrant
coagulation parameters, the complications of bleeding were significantly low. 5) As it is well
known, alcohol is the major cause of cirrhosis of liver. 6) Poor control of diabetes was
observed among the cirrhotic patients undergoing paracentesis. 7) Co-morbidities like
cerebrovascular disease, IHD, and CKD are significantly higher in cirrhotic patients. 8)
Almost more than 90% patients were dyslipidemic with low statins usage which should be
addressed as the mortality increases.

Conclusions
Even with abnormal coagulation, paracentesis is a safe procedure. But significant co-
morbidities should be addressed with care in cirrhosis patients. Ultrasound guidance during
the procedure whenever required should be encouraged.

Equipment
The equipment required can be found in a disposable
paracentesis/thoracocentesis kit (see the image below).
Paracentesis/thoracocentesis tray.
Equipment includes the following:
 Antiseptic swab sticks
 Fenestrated drape
 Lidocaine 1%, 5-mL ampule
 Syringe, 10 mL
 Injection needles, 22-gauge (two)
 Injection needle, 25-gauge
 Scalpel, No. 11 blade
 Catheter, 8 French, over 18-gauge × 7.5-in. needle with three-way
stopcock, self-sealing valve, and a 5-mL Luer-Lok syringe
 Syringe, 60 mL
 Introducer needle, 20-gauge
 Tubing set with roller clamp
 Drainage bag or vacuum container
 Specimen vials or collection bottles (three)
 Gauze, 4 × 4 in.
 Adhesive dressing

Contraindicații
- coagulopatii severe, necorectate prin administrare de vitamina K sau plasma proaspata
- trombocitopenie severa sub 20.000/mm3, INR>2
- pacienti cu hemoragie digestiva
- interventii chirurgicale in antecedente cu existenta adeziunilor si bridelor intraabdominale
postoperatorii
- distensie abdominala severa
- celulita de perete abdominal (in special la locul punctiei).
- abdomen acut chirurgical
- colectii inchistate
- obezitatea
- diatezele hemoragice
- glob vezical
- imposibilitatea pacientului de a sta nemiscat in timpul efectuarii paracentezei
- contaminarea probei cu sange, bila, urina, fecale.
- chisturi ovariene, hidronefroză, sarcină.

Pacientii sunt sfatuiti sa contacteze imediat medicul daca dupa paracenteza apare:
- febra
- durere abdominala intensa
- inrosirea zonei si umflarea concomitenta a abdomenului
- hematurie
- hemoragie locala
- supuratii si diverse scurgeri locale.

Complicații
Parerile specialistilor sunt impartite. Unii considera ca manevra in sine reprezinta cauza
de infectie a lichidului de ascita, insa numeroase studii au demonstrat faptul ca paracenteza este
o procedura sigura si asociaza un risc de sub 1% de a dezvolta complicatii majore si tot sub 1%
pentru aparitia complicatiilor minore.
Cea mai de temut complicatie ramane perforarea unui viscer abdominal (ficat, splina) sau a
unor organe cavitare(anse intestinale, vezica urinara)
Alte complicatii posibile:
- hemoragie digestiva si intraperitoneala (ca urmare a lezarii venelor ombilicale sau
decompresiunii bruste a cavitatii peritoneale)
- colaps vascular
- edem scrotal
- hematom de perete abdominal
- contaminarea lichidului de ascita
- peritonita
- şoc, tulburări hidroelectrolitice care sunt prevenite prin eliminare lentă;
- hipotensiune arteriala (cand se extrag mai mult de 1500 ml de lichid, foarte rapid); exista situatii
dramatice cand se poate ajunge chiar in soc; pacientii vor primi in acest caz fluide perfuzabile si
medicamente ce vor readuce tensiunea arteriala la valori normale
- afectarea functiei renale.
- imposibilitatea pătrunderii trocarului (se incizează tegumentul cu vârful bisturiului )
- puncţie negativă, prin obstrucţia acului cu fragmente tisulare (se introduce xilină sau ser
fiziologic pentru dezobstruare sau se repetă puncţia în alt loc)
- oprirea scugerii lichidului peritoneal denotă obstrucţia acului cu un franjur epiploic sau cu
membrane fibrinoase (se va încerca minima mobilizare a acului sau repetarea puncţiei)
- sincopa (reflexul vagal sincopal poate aparea datorita inteparii peritoneului sau evacuarii prea
rapide a unei cantitati mari de lichid): se va practica resuscitarea cardiorespiratorie
- fistule parietale la locul punctiei
- supuratii locale( nerespectarea masurilor de asepsie si antisepsie)

Ascitic fluid leak — The most common complication following paracentesis is an


ascitic fluid leak, which occurred in 5 percent of patients in one study [9]. Leaks typically
arise when a Z-track has not been performed properly, a large-bore needle has been
used, and/or a large skin incision has been created. We have rarely encountered a leak
using the technique described above. (See 'Paracentesis techniques' above.)

Bleeding — Bleeding from an artery or vein that is impaled by the needle can be
severe and potentially fatal [9]. An external figure-of-eight suture can be placed surrounding
the needle entry site if the inferior epigastric artery is bleeding. Rarely, a laparotomy is
required to control the hemorrhage. The risk of serious bleeding appears to be higher if renal
failure is present [8]. Patients with primary fibrinolysis may develop three-dimensional
hematomas and require antifibrinolytic treatment [4]. (See 'Abnormal coagulation studies and
thrombocytopenia' above.)

Bowel perforation and infection — Infection is rare unless the bowel is entered by the
paracentesis needle [9,13]. Bowel perforation by the paracentesis needle occurs in
approximately 6/1000 taps. Fortunately, it usually does not lead to clinical peritonitis and is
generally well tolerated [19]. Treatment is not required unless patients develop signs of
infection (eg, fever, abdominal tenderness).

Mortality — Death due to paracentesis is exceedingly rare (zero in most series) [5-7]. In the
two largest series, there were a total of nine deaths out of 5244 procedures (mortality rate
0.16 to 0.39 percent) [8,9]. Eight of the deaths were due to bleeding, and one was due to
infection.

In one large randomized controlled trial, therapeutic


paracentesis plus IV infusion of colloid led to fewer minor
(asymptomatic) changes in serum electrolyte and creatinine
levels than those reported with diuretic therapy; however, no
differences in morbidity or mortality rates could be demonstrated.
141 Therapeutic paracentesis now appears to be firstline
therapy for patients in whom ascites is tense and
second-line therapy for patients with cirrhosis whose ascites
is refractory to diuretics (see Fig. 93-5).10 The world record for
volume of fluid removed at one time appears to be 41 L.14

A meta-analysis has reported a survival advantage with


albumin infusion after large-volume paracenteses.148 Therefore,
it seems reasonable to (1) avoid serial large-volume paracenteses
in patients with diuretic-sensitive ascites, (2) withhold
albumin after taps of 5 L or less, and (3) consider albumin
infusion (6 to 8 g/L of fluid removed) after taps of larger
volume in patients with diuretic-resistant ascites.

●A prospective study of 1100 large-volume paracenteses documented no bleeding


complications with no pre- or post-procedure transfusions required despite INRs as high
as 8.7 and platelet counts as low 19,000/mL [7].

●In another report (in which occasional patients received prophylactic fresh frozen
plasma, platelets, or desmopressin [DDAVP]), severe bleeding was observed in only 9
of 4729 paracenteses (0.19 percent) [8]. The mortality rate attributable to the procedure
was 0.016 percent. Eight of the nine patients who bled had renal failure, suggesting that
the qualitative platelet dysfunction associated with renal failure contributed to the
bleeding risk. Thus, it may be reasonable to use DDAVP before performing
paracentesis in patients with cirrhosis and renal failure, although no studies have
formally established a benefit. (See "Platelet dysfunction in uremia".)
●A somewhat higher complication rate (1.6 percent) was reported in a prospective study
of 515 paracentesis in patients with cirrhosis [9]. Five patients bled, three developed
infections, and two died. However, one of the complications was "catheter residue
broken into abdominal wall," which taken together with the relatively high complication
rate, raises concern as to whether there were specific technique-related factors that
may have contributed to the adverse outcomes.

Complications
Complications from paracentesis may include the following:
 Failed attempt to collect peritoneal fluid
 Persistent leak from the puncture site
 Wound infection
 Abdominal wall hematoma
 Spontaneous hemoperitoneum - This rare complication is due to
mesenteric variceal bleeding after removal of a large amount of ascitic
fluid (>4 L).
 Hollow viscus perforation (small or large bowel, stomach, bladder)
 Catheter laceration and loss in abdominal cavity
 Laceration of major blood vessel (aorta, mesenteric artery, iliac artery)
 Postparacentesis hypotension
 Dilutional hyponatremia
 Hepatorenal syndrome [19]

A prospective study of 171 patients undergoing paracentesis found that


"major" complications occurred in 1.6% of procedures and included five
episodes of bleeding and three infections, resulting in death in two cases.
Major complications were associated with therapeutic but not diagnostic
procedures and tended to be more prevalent in patients with low platelet
counts (<50 × 109/L), patients who were Child-Pugh stage C, and patients
with alcoholic cirrhosis. [8]
in a systematic review and meta-analysis of 10 trials comprising 462 patients with
cirrhotic ascites, Guo et al reported that midodrine, a vasopressor, used as a novel
threapy for the ascites caused by cirrhosis did not improve survival but potentially
improved response rates and reduced plasma renin activity. [18] However, when
midodrine was used as an alternative to albumin in large-volume paracentesis, the
mortality was higher for those receiving midodrine than for those receiving
albumin;midodrine and albumin had a similar association with the
development paracentesis-induced circulatory dysfunction. [18]
Conservative management appears to be the treatment of choice for patients with
chylous ascites. [3]

 In a multicenter study that assessed the safety and efficacy of an automated pump system
for the treatment of refractory ascites in 40 patients at 9 centers, Bellot et al reported the
automated pump was an efficacious tool to remove ascites from the peritoneal cavity to
the bladder. [11] During the 6-month follow-up period, 90% of the ascites was removed with
the pump system; there was also a significant reduction in the monthly median number of
large volume paracentesis as well as a reduction in the number of cirrhosis-related
adverse events. [11]
 Therapeutic paracentesis may be performed in patients who require rapid symptomatic
relief for refractory or tense ascites. When small volumes of ascitic fluid are removed,
saline alone is an effective plasma expander. [12] The removal of 5 L of fluid or more is
considered large-volume paracentesis. [1] Total paracentesis, that is, removal of all ascites
(even >20 L), can usually be performed safely.

Contraindications
An acute abdomen that requires surgery is an absolute contraindication.
Severe thrombocytopenia (platelet count <20 × 103/μL) and coagulopathy
(international normalized ratio [INR] >2.0) are relative contraindications.
Patients with an INR greater than 2.0 should receive fresh frozen plasma
(FFP) prior to the procedure. One strategy is to infuse one unit of fresh
frozen plasma before the procedure and then perform the procedure while
the second unit is infusing.
Patients with a platelet count lower than 20 × 103/μL should receive an
infusion of platelets before the procedure.
In patients without clinical evidence of active bleeding, routine laboratory
tests such as prothrombin time (PT), activated partial thromboplastin time
(aPTT), and platelet counts may not be needed before the procedure. [7] In
these patients, pretreatment with FFP, platelets, or both before
paracentesis is also probably not needed.
A study of 608 patients (72% with alcohol-related liver disease) found a low
overall rate of complications that required transfusions (0.2%) and a higher
incidence of significant hemoglobin drop among those with severe renal
failure (creatinine > 6 mg/dL). [7]
A prospective study of 171 patients undergoing paracentesis found that
"major" complications occurred in 1.6% of procedures and included five
episodes of bleeding and three infections, resulting in death in two cases.
Major complications were associated with therapeutic but not diagnostic
procedures and tended to be more prevalent in patients with low platelet
counts (<50 × 109/L), patients who were Child-Pugh stage C, and patients
with alcoholic cirrhosis. [8]
Other relative contraindications include the following:
 Pregnancy
 Distended urinary bladder
 Abdominal wall cellulitis
 Distended bowel
 Intra-abdominal adhesions
Depending on the clinical situation, fluid may be sent for the following laboratory
tests:
 Gram stain - In a retrospective review of 796 peritoneal fluid samples, the evaluation of
Gram stain results rarely provided clinically useful information for the detection of
spontaneous bacterial peritonitis [9]
 Cell count (elevated counts may suggest infection)
 Bacterial culture
 Total protein level
 Triglyceride levels (elevated in chylous ascites)
 Bilirubin level (may be elevated in bowel perforation)
 Glucose level
 Albumin level, used in conjunction with serum albumin levels obtained the same day
(used to calculate SAAG; see the Ascites Albumin Gradientcalculator)
 Amylase level (elevation suggests pancreatic source)
 Lactate dehydrogenase (LDH) level
 Cytology
After proper antiseptic preparation and local anesthesia, a diagnostic tap can be
performed with a 10- to 20-mL syringe and an 18-gauge needle.
After proper antiseptic preparation and local anesthesia, a therapeutic tap can be
performed with an intravenous (IV) catheter over the needle connected to drainage
tubing.
In patients who are afebrile, alert, and have no other signs of bacterial peritonitis,
ascitic fluid labs are often not necessary to rule out SBP). [10, 11]
To minimize the risk of persistent leak from the puncture site, use a small-gauge
needle or take a "Z" track during insertion of the needle. (During removal of the
needle, the subcutaneous tissue seals on itself.)
In a retrospective review of 796 peritoneal fluid samples, the evaluation of Gram stain
results rarely provided clinically useful information for the detection of SBP. [9]
Dietary sodium restriction and diuretics do not often provide symptomatic relief of
refractory ascites in patients in advanced stages of cancer. Although paracentesis
does effectively drain ascitic fluid, the condition invariably recurs, and repeated
procedures are necessary. A 2008 study reported that a permanent peritoneal
catheter to drain abdominal fluid greatly reduced the symptoms of ascites in these
patients and avoided the costs and complications of frequent paracentesis
procedures. [12]
A meta-analysis suggests that the use of albumin in cirrhotic patients undergoing
paracentesis reduces paracentesis-induced circulatory dysfunction and reduces
death and renal impairment. [13]
Complication prevention
In cases with a persistent leak, a single skin suture might solve the problem. The
application of an ostomy bag around the puncture site keeps the leak contained until
it is eventually sealed off.
Postparacentesis hypotension is a delayed complication that may occur more than 12
hours after a procedure in which large volumes are taken off. Patients can be
pretreated with a colloid solution, such as albumin, to decrease the frequency of this
complication, though no difference in survival has been noted relative to other
plasma expanders. [14]
Timing of paracentesis
Whereas studies suggest that early paracentesis (<12 hours from admission)
improves short term survival of hospitalized patients with SBP in comparison with
delayed paracentesis, it seems that earlier administration of appropriate antibiotics in
the early paracentesis group might have been a major contributing factor. [15, 16]
At this time and in the absence of prospective, randomized, controlled data, the
authors recommend early diagnostic or therapeutic paracentesis and early empiric
antibiotic administration in patient suspected of having SBP. When it appears that
large-volume paracentesis is likely to be required, the authors suggest consideration
of early small-volume paracentesis (ultrasound, syringe, and needle technique)
followed by delayed and planned large-volume paracentesis (during hospitalization)
under appropriate monitoring and hemodynamic support to minimize the risk of
circulatory dysfunction induced by large-volume paracentesis.

Positioning
Patients with severe ascites can be positioned supine. Patients with mild ascites may
need to be positioned in the lateral decubitus position, with the skin entry site near the
gurney. The lateral decubitus position is advantageous because air-filled loops of bowel
tend to float in a distended abdominal cavity.
The two recommended areas of abdominal wall entry for paracentesis are as follows
(see the image below):
 2 cm below the umbilicus in the midline (through the linea alba)
 5 cm superior and medial to the anterior superior iliac spines on either side

Paracentesis: standard sites.


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The authors recommend the routine use of ultrasonography to verify the presence of a
fluid pocket under the selected entry site in order to increase the rate of success (see
image below). [17]
Ultrasonogram showing
ascites.
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The use of ultrasonography also helps the practitioner avoid a distended urinary
bladder or small bowel adhesions below the selected entry point. To minimize
complications, avoid areas of prominent veins (caput medusae), infected skin, or scar
tissue.