1) Abdominal paracentesis is a procedure where a needle is inserted into the peritoneal cavity to remove ascitic fluid. It can be performed for diagnostic purposes to obtain a small fluid sample for testing or therapeutically to remove over 5 liters of fluid. 2) The optimal site for paracentesis is the left lower quadrant of the abdomen to access the thicker abdominal wall and larger fluid pool. Ultrasound guidance can be used. 3) After marking the skin and administering local anesthesia using the "Z-track" technique, the needle is slowly inserted while aspirating to check for blood. Fluid flow indicates proper needle placement in the peritoneal cavity.

2.  Abdominal paracentesis is a bed side clinical
procedure in which needle is inserted into
peritoneal cavity nd ascitic fluid is removed.
TYPES:-1)diagnostic small quantity of fluid is
removed for testing.
2) therapeutic:>5 litres of fluid is removed to
reduce intraabdominal pressure and
relieve the asso. Symptms like dyspnoea,
abdmnl pain nd early satiety.

3.  For evaluation of new onset ascites.
 Testing of ascitic fluid.
 For evaluation of pt with ascitis who has
signs of clinical deterioration like
fever,abd.pain,hepatic
encephalopathy,decreased renal function n
metabolic acidosis.
 Paracentesis can identify unexpected
diagnosis such as chylous, hemorrhagic or
esinophilic ascites useful to know etiology n
antibiotic susceptibility.

4. Pt with DIC – risk is decreased by
administering platelets or FFPs.
Primary fibrinolysis(pt with 3 dimensional
bruises) treat with aminocaproic acid or IV
tranexamic acid.
Massive ileus with bowel distension.
Near the surgical scar bcoz scars are asso.
With tethering of bowel to abd.wall n will
cause bowel perforation.
Infections

5. Abnormal coagulation studies like increased
INR n Thrombocytopenia are not
contraindications.
70% pts with Ascites have abnormal PT but risk
of bleeding is low.
Pt who bleed had renal failure suggesting
qualitative platelet dysfunction asso. With
renal failure. Here desmopressin may be
used before paracentesis in pts with cirrhosis
and renal failure.

6. Explain the procedure & Obtain Consent
No fasting before Procedure
EQUIPMENT & STAFF
Clinician & Assistant
Bottles should be labelled for tests prior
doing paracentesis
Bacterial culture is done in pts with SBP

7. DIAGNOSTIC: 1.5 Inch, 22 Gauge needle
For Obese :3.5 Inch, 22 Gauge spinal needle
THERAPEUTIC: 15/ 16 Gauge needle to
speed up the removal.
KIMBERLY – CLARK QUICK TAP
PARACENTESIS TRAY CONTAINS
CADWELL NEEDLE which has a sharp inner
trocar & blunt outer metal cannula with side
holes to permit withdrawal of fluid if end hole
is occluded by bowel/ Omentum

8. Mostly Supine
Head may be elevated
Knee elbow position for removal of minimal fluid
in dependent area
SITE
Lt lower Quadrant (Dullness on percussion)
3cm medial & 2cm above the ant. Sup. Iliac
spine
Not near umbilicus bcoz of presence of
collateral vessels
Surgical scars & visible veins should be
avoided.

10. Abd. Wall is thinner.
Pool of fluid is more.
Pt can be rolled easily to left for drainage.
WHY NOT RIGHT???
Appedicectomy scar, caecum filled with gas in
pts taking lactulose.
Care must be taken not to injure inferior
epigastic artery which bleeds massively &
which is located near pubic tubercle

11. Mark the site as “X” & positions 12, 3, 6, 9 a
few centimeters from “X”
Sterilise with Iodine or Chlorhexidine
Solution starting from X using widening
circular motions.

12. Anaesthetise using 3- 5 ml of 1% Lignocaine
Solution in a “Z” track technique.
Needle used for it is 1.5inch which is sufficiently
long.
Choose the site & pass the needle tangentially,
raising a wheal with Lignocaine.
“Z” track creates a non linear pathway b/n
Skin& Ascitic fluid & minimise the chance of
leakage.

14.  With one hand pull the abdominal wall n with
other hand operate the syringe. Hand on the
abd.wall should not be removed untill the
needle enters the fluid.
 Insert the needle n syringe 5mm deep
pull the plunger back with each advancement
to see if any blood is aspirated.
then inject the lignocaine sol.
Cont. the same procedure until the needle enters
fluid.

15. Aspiration should be intermittent not
continuous.
Cont. may pull the bowel or omentum onto
needle tip,occluding the tip.
Yellow color fluid indicates needle is in the
peritoneal cavity.
NEEDLE INSERTION:
Needle is inserted along anesthetised
pathway after nick is given with 11 no. blade.
Fliud should drip from the hub of the needle.
 Larger the nick greater the post paracentesis
leak.

16.  Ultrasound guidance cab be used to guide
the procedure.
 During laproscopy parietal peritoneum may
form tenting over needle n fluid doesn’t
come.
 Operator cant see this n may mis interpret as
DRY TAP.
 Rotating the needle for 90 degrees or more
will pierce the peritoneum n help the
drainage.

17. Small amount of fluid may be difficult to drain
bcoz omentum/bowel may block the end of
needle. So multi hole needles are helpful.
Misconception of poor flow is LOCULATION.
True loculation is seen in peritoneal
carcinomatosis with malignant adhesions or
bowel rupture with surgical peritonitis.
Loculation never occur in cirrhosis or heart
failure with ascites or SBP.

18. Stable needle n depth of penetration of
needle are crucial for successful
paracentesis.
TESTING
 25 ml fluid is enough for cell count,diff
count,chemical testing n bacterial culture.
 In TB 50ml for cytology
 50ml for smear n culture.

19. It is removal of >5 lit of fluid.
In refractory ascites,removal of as much fluid as
possible with sod.restricted diet n diuretics will
extend the interval to next paracentesis.
REMOVAL OF NEEDLE:
Needle is removed with one rapid smooth
withdrawal motion.
Distract the pt by asking him to cough
bcoz cough will prevent pain sensation.

21.  Ascitic fluid leak:
-improper Z track
-using large bore needle
-large skin nick
Rx: keep ostomy bag over nick.
 Bleeding:
-artery or vein
In inferior epigastric bleed fig. of 8 suture is
placed surrounding the needle site.

22.  Rarely laprotomy is needed to control
bleeding in pts with renal failure n
hyperfibrinolysis.
 Bowel perforation
 Infections
 Catheter residue broken into adb.wall.