Healthcare and Medicine Reference
In-Depth Information
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Use a scalpel blade to make a small nick in the skin to allow for
Ascitic leakage. This is one of the commonest complications fol-
easy catheter access (Figure 16.2e). Insert the catheter perpen-
dicular to the selected entry point (Figure 16.2f). Insert slowly
in increments of 5 mm to minimise the risk of inadvertent
vascular entry. Continuously apply suction to the syringe as the
needle is advanced.
Sudden loss of resistance is felt when you enter the perito-
lowing paracentesis. Ascites can leak from the puncture site, often
for several days after the procedure. Ostomy bags can be used
around the puncture site to keep the leak contained until it even-
tually ceases. Several hundred mL of fl uid can drain into the bag
every day and some patients fi nd this advantageous in controlling
their ascites. Alternatively a single suture can be applied to close
the puncture site.
Failed paracentesis.
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neal cavity and ascitic fl uid can be aspirated into the syringe
(Figure 16.2g). At this point, advance the catheter a further
5 mm into the peritoneal cavity. Avoid advancing the catheter
any deeper.
Use one hand to fi rmly hold the trocar and syringe in place
Late complications
Postparacentesis hypovolemia and hypotension. This is the most
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to prevent the trocar from entering further into the perito-
neal cavity. Use the other hand to advance the plastic catheter
over the trocar all the way into the peritoneal cavity
(Figure 16.2h). Resistance should not be felt while the catheter
is advanced. Resistance could mean that the catheter has been
misplaced. If resistance is felt withdraw the catheter completely
and reattempt the procedure.
Remove the trocar once the plastic catheter is completely
important physiological phenomenon that frequently compli-
cates paracentesis, especially in the setting of cirrhosis of the
liver. As discussed earlier, renal failure can occur as a result of the
haemodynamic changes following paracentesis. The risk of renal
failure is especially increased in patients with spontaneous bacte-
rial peritonitis or pre-existing renal impairment. Administration
of human albumin corrects intravascular hypovolemia and is the
single most important therapeutic intervention that could prevent
renal failure following large-volume paracentesis in cirrhosis.
Frequent monitoring of vital signs following paracentesis is
important in identifying haemodynamic changes and correcting
them appropriately.
Hyponatraemia.
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inserted, and attach the three-way stopcock and a catheter bag.
Ascitic fl uid should drain completely within 4-6 hours through
gravity.
Secure the drain with sutures or an appropriate purpose-made
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dressing (Figure 16.2j). Use the 'Z' technique, to avoid leakage
of ascites post procedure. This involves stretching the skin a
couple of centimetres in any direction over the deep abdominal
wall. The catheter is then inserted into the peritoneum. Upon
releasing the skin a Z tract is created in that the entry points
in the skin and the peritoneum are not directly against each
other. Although there is little evidence to back up this theory,
it is believed to minimise the risk of persistent leak from the
puncture site.
Hepatorenal syndrome.
Handy hints/troubleshooting
Always check the clotting: a recent INR and platelet count should
be assessed before starting the procedure.
In obese patients the 21G green needle may not be long enough
to reach the peritoneum. Use a needle from a green cannula
(18G) which is much longer than a standard 21G needle.
Ensure the drain is well secured.
Complications
Paracentesis is a very safe procedure, and complications are rare if
simple precautions are exercised.
Ensure there is a clear plan documented in the notes regarding
drainage volumes and replacement fl uids.
Further reading
Immediate complications
Abdominal wall haematoma.
Gines P, Tito L, Arroyo V et al. (1988) Randomized study of therapeutic
paracentesis with and without intravenous albumin in cirrhosis.
Gastroenterology 94: 1493-502.
Moore KP, Aithal GP. (2006) Guidelines on the management of ascites in
cirrhosis. Gut 55: 1-12.
Panos MZ, Moore K, Vlavianos P et al. (1990) Single total paracentesis for
tense ascites: sequential haemodynamic changes and right atrial size.
Hepatology 11: 667.
Saber AA, Meslemani AM. (2004) Safety zones for anterior abdominal wall
entry during laparoscopy: a ct scan mapping of epigastric vessels. Ann Surg
239(2): 182-5.
Haemoperitoneum. This rare complication can result from
trauma to a major blood vessel or intraabdominal varices at the
time of insertion of the peritoneal catheter.
Hollow viscus perforation. Simple precautions like careful selec-
tion of the entry site with attention to avoiding scars and obvious
abdominal wall veins should minimise the risk of hollow viscus
perforation or bleeding. Alternately an ultrasound scan can be
performed before the procedure to select the entry site.
Liver or splenic laceration.
Catheter laceration and loss in abdominal cavity.
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