The LSUHSC New Orleans
Emergency Medicine Interest Group
The Student Procedure Manual
by Aruna Akundi with
Contraindications (all relative)
- Diagnostic tool to determine the etiology of ascites fluid, once it has been
proven to exist by physical exam and/or ultrasound, and to ascertain if infection
- Therapeutic intervention to drain large volumes of abdominal ascites for improving
pulmonary function or diminishing abdominal pain from distention.
Contraindications (all relative)
- Prothrombin Time prolonged > 6 seconds over control and a platelet count
- Some discount coagulopathy as a relative contraindication, if paracentesis is
performed in the relatively avascular midline.
- Distended bowel- risk of bowel perforation especially in obstructed bowels
and in patients with possible adhesions from previous abdomen surgery.
- Uncooperative patient
- Pt should have an empty bladder. If pt cannot accomplish this', then a Foley
catheter must be placed
- Pt's prothrombin time, partial thromboplastin time, and platelet count should
be evaluated and corrected due to risk of hemorrhage.
- Antiseptic solution and drapes
- 1 % Lidocaine
- 18- or 20 gauge needle and syringe
- Place patient in supine or lateral decubittis position.
- The ideal puncture site is in the left lower quadrant of the abdomen, lateral
to the rectus abdominis muscle , in the midclavicular line, inferior to the
- Alternate sites may be preferred depending on the location of the fluid and
the purpose of the tap.
- Point of entry should remain lateral to the rectus abdominis muscle to avoid
injury to the inferior epigastric artey and vein.
- Avoid the upper abdominal quadrants in case of undetected hepatosplenomegaly.
- Avoid visible, collateral venous channels (caput medusa) on the abdominal wall.
- Avoid known sites of abdominal surgery where adhesions may be present.
- After appropriate sterile preparation, infiltrate 1% Lidocaine subcutaneously
to the peritoneum.
- Refer to the Intramuscular Injection procedure to perform a "Z seal"
to prevent persistent ascitic leakage at site.
- Insert an 18- or 20- gauge short beveled spinal needle attached to a syringe
through the abdominal wall. Different sizes and types of needles or catheters
may be used depending on the purpose of paracentesis.
- Withdraw at least 50ml of ascitic fluid for adequate study. Some situations
may necessitate larger quantities ranging from I to 3 liters, as in tense ascites.
*Note: Special paracontosis needles, "needle-over-catheter", can
be used for this procedure and are preferred in that the risk of parenchymal
injury is reduced.
- Ascites fluid can be sent for lab analysis: cell count (heparinized tube)
and differential, total protein, glucose, specific gravity, amylase, LDH,
bacterial and mycobacterial cultures and cell block pathology (heparinized
- Persistent ascitic leak
- Intestinal or urinary bladder perforation with associated peritonitis and
- Transient hypot6nsion in pts with large-volume chronic abdominal ascites such
as that secondary to hepatic cirrhosis or ovarian carcinoma
- Intraperitoneal air
- Glauser JM. Paracentesis. In: Roberts JR, Hedges JR, eds. Clinical Procedures
in Emergency Medicine. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1991:
- Napolitano LM. Paracentesis. In: Rippe JM, et al. eds. Procedures and
Techniques in Intensive Care Medicine. Philadelphia, Pa: Little, Brown
and Co; 1995: 207-209.
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