Paracentesis

Consent: Prior to performing the procedure, consent must be obtained from either the patient or a surrogate decision maker, and the proper consent form must be signed. Review the procedure, potential benefits, potential risks, and complications.

Position: Raise the patient’s bed to an appropriate height to avoid hunching over during the procedure. Put the bed rail down at the side from which you will be performing the procedure. Patient should be lying supine in the bed with head slightly elevated.

Ultrasound Survey: Utilizing the phased array probe, you will use the ultrasound to find an appropriate site for paracentesis. The probe marker should be facing the patient's head.

1. Landmarks: Assess the right or left lower quadrants lateral to the rectus sheath to avoid puncture of the inferior epigastric vessels. Given the dependent nature of ascitic fluid in the peritoneal cavity, the more lateral you are, the larger and more accessible window. You can also consider the sub-umbilical approach in which you will puncture at a site 2 cm below the umbilical in the midline, however, you must ensure patient has emptied their bladder prior to procedure.

2. Ideal Site: Ascitic fluid that is ideally at least 3 cm deep that is devoid of loops of bowel or surrounding organs. Once you find a potential site, fan and rock the ultrasound to ensure no bowel loops enter the site. If unable to find a deep enough accessible window without surrounding organs, the procedure must be aborted.

Mark: Mark the site using a 5 cc syringe by using pressure against the blunt end of the syringe to the skin. Draw back on the syringe, hold for a few seconds, and then remove. Once the site is marked, confirm the position with your ultrasound. Once confirmed, you will no longer need the ultrasound during the procedure.

Sterilize: Put on sterile gloves (see sterile approach tab for more detailed information). Open the chloraprep antiseptic swabstick included in the paracentesis kit. Sterilize the insertion site you located previously, starting at the insertion site and moving outwards in a circular manner for at least 2 min. Allow it to completely dry before starting the procedure.

Drape: The drape is included within the paracentesis kit. Remove the sticker lining. Align the opening of the drape at the cannulation site and stick the drape onto the site.

Time Out: Physician and RN will perform time out together in front of the patient. You will confirm the 3 P’s - proper patient, procedure, and location. Review allergies and confirm that informed consent was obtained.

Anesthetize: Open the lidocaine, and attach the blunt needle to the syringe. The blunt needle allows you to draw the lidocaine into the syringe as it has a bigger diameter, however, you cannot inject the patient using this needle. Once lidocaine is drawn into the syringe, change the blunt needle tip to 22 or 25 gauge anesthetizing needle. Create a wheal at the site of insertion, however, aspirate prior to pushing lidocaine to ensure you are not in a vessel. Once a wheal is created, you will anesthetize deeper along the tract of the catheter. Insert your needle vertically into the insertion site, aspirate to ensure no blood return, push medication, advance needle and repeat (Advance, Aspirate, Push Medication). Do this until you feel a sudden loss of resistance indicating the needle has entered the peritoneal cavity, and inject additional anesthetic as the parietal peritoneum is highly sensitive. Withdraw the needle.

Puncture: Using a scalpel, puncture the marked site by inserting the blade straight down a few cm to create a nick to allow for passage of the catheter. Tip: Inserting the blade is a more effective technique rather than using a flicking motion.

Positioning needle: The catheter component includes the needle within the catheter, stop cock, and 10 cc syringe for aspiration. Using your dominant, hold the plunger of the syringe to allow you to aspirate throughout the procedure. Rest the dorsal surface of your nondominant hand against the patient’s abdominal wall for stability while holding the distal end of the catheter with your thumb and first finger. This will allow you to feed the catheter through the puncture site you created while stabilizing yourself against the patient and preventing the catheter from bending.

Insertion: There are two techniques detailed below for inserting the needle that will prevent prolonged leakage of ascitic fluid from the puncture site by preventing direct overlap of the cutaneous insertion site and the peritoneal insertion site - the z tract technique and the angular insertion technique. Pull back on the syringe plunger as you advance the needle until you feel a loss of resistance entering the peritoneal cavity and aspirate ascitic fluid within the syringe. Once you see this, advance the needle 1-2 mm further and reconfirm good flow of peritoneal aspirate within the syringe.

1. Z Tract Technique: Pull the subcutaneous tissue down and then insert the catheter at a 90 degree angle through the puncture site you created.

2. Angular Insertion Technique: Insert the catheter at a 45 degree angle into the puncture site.

Advance catheter: While holding the syringe, brace your dominant arm against you so that the needle doesn’t move. Use your non-dominant hand to advance the catheter until it is flush with the skin, and then remove the needle (See how to advance the catheter in equipment checklist section)

Collection:

1. Diagnostic: Turn the stopcock so that it is facing away from the patient. This will ensure that the component is open towards the patient and towards the third component of the 3 way stop cock to which you will attach the 60 cc syringe. Withdraw ascitic fluid, remove the 60 cc syringe from the stop cock, and pour it into the available vials within the kit, a grey top container in case the lab needs additional fluid for studies, and cytology vial if indicated.

2. Therapeutic: Attach the tubing of the high pressure drainage system to the catheter. You can either attach the distal end of the tubing to the drainage bag. Or you can attach the spiked tip component to the distal end of the tubing, and then insert the spiked end into an evacuation container. If > 5L are removed in a large volume paracentesis, give 6 g of albumin for every 1L removed. 1 bottle of 25% albumin has 25 g in 100 cc.

Dressing: Once you are finished, remove the catheter, apply pressure against the site with gauze, and then apply a bandaid.