Edited J Chase 6/2014

UCSF Family Medicine Inpatient Service Procedure Training: Paracentesis with ultrasound guidance Equipment:

IV access Paracentesis kit Caldwell Needle (optional) Supportive care and monitoring as needed Mask & visor/sterile gloves per participant Ultrasound machine (for procedure guidance)

Procedure:

Explain the procedure and obtain informed consent. Pre-medicate as necessary. Set up monitoring as needed. Conduct a pre-procedure time out to verify correct patient, correct procedure, correct side and completed consent. Observe universal precautions (fenestrated drape, sterile gloves, mask with visor) and sterile technique. Place the patient in an supine position with the head of the bed at 30° (image #1). Paracentesis approach: lateral left or right lower abdominal quadrants or the midline below umbilicus. Avoid the semilunar lines, where the inferior epigastric arteries are located (Image #2). If using a lateral (LLQ or RLQ) approach, consider placing a pillow under the patient’s contralateral side. Use ultrasound to visualize peritoneal fluid and local structures, including omentum and bowel (Image #2). Locate a window of fluid > 3cm (depth between the parietal peritoneum and the nearest bowel or omentum.) Mark the site with a surgical marking pen. Freeze and print the image for documentation. US guidance has been shown to reduce risk of bleeding, LOS and overall cost of paracentesis (by reducing complications). **If concern for an overlying vessel, choose an alternative site or contact your attending physician, an ultrasound technician or an interventional radiologist to use ultrasound doppler mode to evaluate.

Cleanse with chlorhexadine and apply fenestrated drape. Using a 5-10 cc syringe and 22 gauge needle, place a wheal of 1% plain lidocaine at the desired site. Advance needle through the wheal into the abdomen at a 90° angle to the skin. Aspirate as you advance the needle. Once peritoneal fluid returns into the needle, you have confirmed the needle depth needed to obtain fluid. Pull the needle back until fluid no longer enters the syringe (directly superficial to the parietal peritoneum). Inject 2-3 cc of lidocaine at this point to anesthetize the peritoneum. Withdraw needle while injecting lidocaine to anesthetize the track for paracentesis. Nick the skin with 11 blade to allow easier passage of paracentesis needle. Option #1) Simple diagnostic aspiration (Image #4): attach an 18 gauge needle of appropriate length to a 50cc syringe. (Use ultrasound to Image  #4:  Simple  diagnostic  aspiration  

Image  #1:  Patient  in  supine  position  with  curved  (abdominal)  ultrasound  probe  in  transverse  

orientation  to  image  the  left  lower  abdomen.  

Image  #3:  Ultrasound  image  of  peritoneal  fluid  (depth  of  2  cm  to  parietal  peritoneum  and  fluid  window  ~8  cm.)      

Image  #2:  Approaches  for  paracentesis  (red  lines  represent  inferior  epigastric  arteries)      

Edited J Chase 6/2014

determine depth to fluid, the hash marks are 1 cm each. For depth > 1.5 inch (3.8 cm) injection needle in the kit, use spinal or Caldwell needle.) Advance the needle along the anesthetized track while aspirating. Once peritoneal fluid returns, stop advancing the needle and aspirate until the syringe is full.

Option #2) Catheter-over-needle insertion technique for large volume paracentesis, and/or therapeutic paracentesis (Image #5-9): Insert the needle-over-catheter along the anesthetized track by applying forward force with your dominant hand while aspirating with the syringe. Use your non-dominant hand to stabilize the catheter at the skin to prevent rapid advancement. Once peritoneal fluid returns, grasp the catheter hub and advance the catheter into the peritoneal space 1-2 cm while holding the syringe and needle steady (Image #7). Holding the catheter steady, remove the syringe and needle (Image #7). If using the plastic catheter, turn the stopcock off to the patient. If using the Caldwell needle, occlude the hub with your finger. Connect the drainage tubing to the catheter hub and connect the distal end of the tubing to the drainage bag or to vacutainer (Image #9). If using the plastic catheter, open the stopcock to the drainage port (Image #8). Drainage is complete when fluid flow stops or desired quantity of fluid is removed. **For paracentesis of > 5L, replete albumin with 50cc of albumin 25% per liter of fluid removed. While studies have mixed results, albumin repletion for > 5L removal is recommended by the AASLD based on a meta-analysis showing decreased mortality.

Post-Procedure/Maintenance:

After aspiration is complete, remove the catheter, clean size with gauze and dress with a bandage.

Send fluid for analysis. Write a procedure note.

References:

- Bernardi M, Carceni P, Navickis RJ, Wilkes MM. Albumin infusion in patients undergoing large-volume paracentesis: a meta-analysis of randomized trials. Hepatology 2012;55:1172-1181.

- Mercaldi CJ, Lanes SF. Ultrasound Guidance Decreases Complications and Improves the Cost of Care Among Patients Undergoing Thoracentesis and Paracentesis. Chest: 143(2):532–538 (2013)

- UCSF Internal Medicine Residency Procedure Training, accessed June, 2014 at http://sfgh.medicine.ucsf.edu

- Partners in Health ultrasound manual at http://www.pih.org - Assorted images from Google Images - ProcedureConsult, accessed May, 2014 at UCSF Library website.

Image  #5:  8  French  plastic  catheter  over  18  gauge  introducer  needle    

Stopcock  

Syringe  Hub  

Catheter  over  needle  

Image  #7:  Advance  the  catheter  into  the  abdomen  while  holding  the  needle  steady.  Remove  the  needle  and  close  the  stopcock  to  the  patient.  

Image  #9:  Catheter  in  place  with  drainage  tubing  connected.    

Catheter  over  needle  

Catheter  

Image  #6:  Caldwell  needle  (a  3.25  inch  blunt  metal  catheter  over  a  15  gauge  needle)    

Image  #8:  In  this  image,  the  stopcock  (red  arrow)  is  “open”  between  needle  and  syringe  and  “off”  to  the  

drainage  port  (center,  connected  to  tubing).  

←OPEN→  

OFF