Healthcare and Medicine Reference
Coagulopathy —There are no data to suggest absolute coagula-
tion parameter cut-offs beyond which paracentensis should be
avoided. It is prudent, however, to administer plasma coagulation
factors immediately before the procedure under the following
INR >2 or
Role of ultrasound
Paracentesis is often an easy procedure to undertake in the presence
of gross ascites and a non-obese subject. Even in the presence of
signifi cant ascites, paracentesis can sometimes be diffi cult in obese
individuals and patients who have undergone multiple abdomi-
nal operations (as fl uid can be loculated and small bowel may
be adherent to the abdominal wall with consequent risk of hol-
low viscus perforation). Ultrasound can be useful in determining
the site for entry, confi rming the presence and the depth of the
pocket of fl uid and in avoiding a distended urinary bladder
(if using the midline approach) or small bowel adhesions below
the entry point.
evidence of DIC or fi brinolysis.
Intravenous vitamin K is a simple and often overlooked
intervention which if given in a timely fashion can lead to correction
of INR before paracentesis.
Severe thrombocytopenia —Patients with platelet counts less than
10 3 /µL should receive an infusion of platelets before under-
going the procedure.
Step-by-step guide: insertion of ascitic drain
Abdominal wall cellulitis .
Give a full explanation to the patient in simple terms and
ensure they consent to the procedure.
Set up your trolley (Box 16.3 and Figure 16.1).
The following conditions can complicate the course of cirrhosis and
caution needs to be exercised when paracentesis is being considered
in these settings:
subacute bacterial peritonitis (SBP)
Prepare your trolley as a sterile fi eld. Wear a plastic
disposable apron and non-sterile gloves, and take alcohol
hand rub with you.
hepatorenal syndrome (HRS)
hepatic encephalopathy (HE).
Haemodynamic changes in cirrhosis are unique, in that there
is signifi cant peripheral and splanchnic vasodilatation, with
consequent decrease in effective circulating arterial volume leading
to renal vasoconstriction and decreased renal perfusion. LVP in
this setting leads to delayed hypovolemia. This typically occurs a
few hours after the procedure and renal impairment can ensue as
a result. SBP and pre-existing renal impairment increase the risk
of renal failure following LVP. Hepatic encephalopathy can be
precipitated or worsened by LVP.
In the presence of cirrhosis-related complications (HRS, SBP,
HE) avoid LVP. Alternately consider limited paracentesis; drainage
of between 2 and 5 L is often suffi cient to relieve symptoms from
large or tense ascites.
Box 16.3 Equipment for insertion of ascitic drain
• or the Bonanno™ suprapubic catheter.
Both of these catheters consist of a straight metal trocar, which
serves as a core for a plastic tube with a curved end that is kept
straight while the trocar is inside. The Bonanno™ catheter has
a small fl at plate on one end that can be taped or sutured to
25G and 21G needles.
Dressing set containing sterile drapes and sterile gloves.
Chlorhexidine solution for cleansing.
Transparent adhesive dressing.
Catheter drainage bag.
Landmarks and anatomy
The two commonest sites used for ascitic drainage are:
midline between the umbilicus and the pubic symphysis (through
the linea alba)
5 cm superior and medial to the anterior superior iliac spine
either side, preferably on the left.
Epigastric blood vessels are usually located in the area between
4 and 8 cm from the midline. Staying away from this area will
determine the safe zone of entry into the anterior abdominal
wall. The midline below the umbilicus is the safest avascular zone.
However, one has to exercise caution to ensure that the urinary
bladder is empty, as the bladder could easily be punctured if it is
full. A simple routine would be to ask the patient to void before
insertion of the peritoneal catheter. Alternatively a bedside bladder
scan could be performed to ensure that the bladder is empty. Avoid
areas of scar tissue as small bowel is often adherent to abdominal
scars and can easily be punctured. Avoid areas containing promi-
nent abdominal wall veins.
Figure 16.1 The equipment required for insertion of ascitic drain.