Paracentesis

Ascites

Indications
Diagnostic :
- Susp of Infection
- Yellowish? Blood? Purulent?
- Malignancy
- SAAG
Therapeutic : Alleviation of discomfort/
dyspnea

Precautions
Severe coagulopathy or
thrombocytopenia
Pregnancy
Organomegaly
Bowel obstruction
Intraabdominal adhesions
Distended urinary bladder (Foley first)

Complications
Large-volume paracentesis- circulatory
dysfunction
Rare: persistent leakage, localized
infection, abdominal wall hematoma
Even more rare: hemorrhage (0.2%
incidence), viscus perforation, arterial
puncture

Procedure

Identify the patient

Obtain consent
Perform a time-out
Identify best site for procedure
Sterilize
Protect yourself
Anesthesia
Paracentesis
Fluid to the lab for analysis
Document procedure and any complications

Lab Evaluation
Is infection present?
Cell count and differential
Suspect SBP if PMN count >250/mm3
Empiric tx w/ cefotaxime or ceftriaxone

If on peritoneal dialysis- >100 WBC w/ >50% PMN

Fluid cultures- 10mL per bottle

Is portal hypertension present?

SAAG >/= 1.1g/dL

SAAG classification

Other lab tests

 A 73-year-old man is brought to the office by his wife after

she found him trying to put his shoes in the refrigerator.
The patient has cirrhosis due to 1-antitrypsin deficiency
and has been taking diuretics for ascites. There is no
history of head trauma or gastrointestinal bleeding.
On physical examination, temperature is 38.4 C (101.1
F). The patient is disoriented to time and place and has
asterixis. Abdominal examination discloses moderate
ascites, and rectal examination demonstrates brown stool.
There are no focal neurologic findings.
Lab data: Hemoglobin 15.8 g/dL

Leukocyte count 9400/L Platelet count 71,000/L

Sodium 128meq/L potassium 4.0meq/L
Creatinine 1.3mg/dL
AST 63 U/L
ALT 71 U/L
total bilirubin 3.2mg/dL albumin 2.8g/dL
INR1.7

Which of the following is most appropriate for

managing this patient at this time?
A Fluid restriction
B Fresh frozen plasma
C Platelet transfusion
D Paracentesis
E CT scan of the head

 Patients with cirrhosis and new or worsening decompensation (as

manifested in this patient by increasing encephalopathy) require
evaluation for a precipitating cause, such as infection, electrolyte
abnormalities, or gastrointestinal bleeding. Because this patient's
fever and ascites indicate possible spontaneous bacterial
peritonitis, diagnostic paracentesis should be performed.

Hyponatremia is common in patients who are taking diuretics for

cirrhosis, and fluid restriction is only necessary when
hyponatremia is severe (sodium <120 meq/L). Diagnostic
paracentesis is safe, even in a patient with mild thrombocytopenia
and coagulopathy, and correction of clotting parameters by
transfusing fresh frozen plasma or platelets is not necessary. A CT
scan of the head is not likely to be helpful in the absence of focal
neurologic findings.