Download Liver - Clinical Departments

Paracentesis
Deborah DeWaay MD
Medical University of South Carolina
April 25, 2013
Objectives
• Knowledge
– Residents should be able to:
• Explain the indications and contraindications for
paracentesis
• Explain the risks and complications of paracentesis
• Explain the appropriate diagnostic testing for
ascitic fluid
• Define the serum-ascites albumin gradient and its
role in the evaluation of ascites
Objectives
• Skills
– Residents should be able to:
• Use sterile techniques during the procedure
• Order and interpret the results of the ascitic fluid
analysis including cell count, differential, gram
stain and culture, albumin (serum and ascites)
• Attitudes:
– Residents should be able to:
• Identify the importance of using ultrasound to
make paracentesis a safer procedure
Key Messages
• Don’t hit the inferior epigastric artery
• Patients with coagulopathy from liver
disease do not need their INR corrected
pre-procedure
• The risk of bleeding is not associated with
coagulopathy
Indications
• Evaluation for spontaneous bacterial peritonitis
– Signs/Sx: fever, abdominal pain, ttp on exam,
encephalopathy, AKI, unexplained acidosis, ↑WBC
• Evaluation of new ascites
– Fluid should be analyzed to look for cause: portal
HTN, cancer, infection…
• Surveillance paracentesis
– Look for asymptomatic SBP in a patient with know
ascites
• Large volume paracentesis
– Shouldn’t be first line: try diuretics first!
Contraindications
• Disseminated intravascular coagulation
disorder
• Problems with skin over the site
– Large veins, cellulitis, hematomas
• Distended intra-abdominal organs
– Make the patient urinate before the
procedure
• Intra-abdominal adhesions or scars
– Bowel may be adhered to the peritoneum
Basic
Anatomy
Inferior
epigastric
aa run
along the
rectus
sheath
The Peritoneal Cavity
• Extends from the diaphragm to the
pelvic inlet
• It is lined with the visceral and parietal
peritoneum
• In a healthy patient it is only a capillary
layer of fluid
Consent
• Risks to procedure
– Postparacentesis circulatory dysfunction
– Persistent leakage of ascitic fluid
– Localized infection
– Abdominal wall hemorrhage
– Intra-abdominal wall hemorrhage (0.2%)
– Intra-abdominal organ injury
– Inferior epigastric artery puncture
Bleeding Risk
• Bleeding risk is VERY low
– 0.19% with a death rate of 0.016%
– The risk of bleeding is not associated with
coagulopathy!
Equipment
• Get familiar with the pre-package kit
available to you
• See the checklist available with this
presentation
Positioning
• For RLQ or LLQ approach, position the
patient supinely with the head slightly
elevated
• For midline infraumbilical approach,
use the left lateral decubitus position
Look Before You Poke
• Examine the abdomen for
– Surgical scars
– Engorged abdominal wall vessels
– Hepatomegaly
– Splenomegaly
• Intestines will usually float out of the
way unless there is adherence
Ultrasound To Mark The Spot
http://app.proceduresconsult.com/Learner/projects/FullDetails.asp
x?ProcedureId=7&procSN=IM-012#
Ultrasound Makes This Safer
• Smaller amounts of ascites can be identified for
tap
• Organomegaly can be avoided
• One study compared abdominal paracentesis
procedures in their institution with and without
ultrasound:
– The indications for paracentesis were similar
between the two groups.
– The incidence of adverse events was lower in
ultrasound-guided procedures includind postparacentesis infection, hematoma, and seroma
– Overall cost of hospitalization was less with u/s
Don’t Hit The Artery!!!
Go 2cm below the umbilicus in the midline or 3 cm
superior and medial to the anterior superior iliac spine
www.uptodate.com
Procedure Anatomy
The Procedure
•
•
•
•
•
Mark the site
Use sterile gloves
Prep the site with chlorhexidine
Apply a sterile drape
Anesthetize the skin: make a wheal with 1%
lidocaine with a 25 gauge syringe. Switch to a 22
gauge syringe and anesthetize deeper tissues.
Alternate pulling back on plunger and injecting to
avoid intravascular injection
• Once into the peritoneum, inject extra lidocaine to
anesthetize the peritoneum
• 5-10cc of lidocaine should be used
The Procedure
• Make sure to use a scapel to nick the
skin before inserting the paracentesis
needle
• Use the Z-tract method to help prevent
leakage post procedure
• Do not apply suction while advancing
because this can draw intestine to the
needle
http://www.uptodate.com/contents/image?imageKey=GAST/76099&topicKey=GAST%2F16203&so
urce=outline_link&search=paracentesis&utdPopup=true
The Procedure
• If you are only doing a diagnostic
paracentesis, use a 60 cc syringe to
withdraw fluid
• If you are doing a large volume
paracentesis, insert tubing from the
needle to the evacuation containers
Post-Procedure
• Apply pressure to the site of puncture
for several minutes
• A pressure dressing is sometimes
helpful in patients with recurrent
ascites to prevent leaks
• Monitor patients with large volume
paracentesis for hemodynamic
instability
What Labs Should Be Ordered?
• Albumin and protein: tube without
additives [Red top tube]
• Cell count and differential: EDTA tube
[Lavender]
• Culture [Use aerobic and anaerobic
blood culture bottles]
• Gram stain [Sterile specimen cup]
• Cytology [Sterile specimen cup]
For MUSC per Lab Client Services
Common Complications
• Post-paracentesis circulatory
dysfunction
– Occurs after ≥ 5L of fluid taken off
– Give 8 gm of Albumin per L of fluid taken
off
• Persistant leaking
– Place a simple suture
Ascites: Why?
• Portal hypertension: cirrhosis (81%)
– There is a disruption of the hydrostaticoncotic pressure imbalance  activation
of the renin-angiotensin system  sodium
retention  volume overload
• Systemic volume overload – CHF
(3%), AKI/CKD, Nephrotic syndrome
• Exudative ascites – TB (2%), cancer
(10%)
• Lymphatic obstruction - cancer
Calculate the SAAG
SAAG = Serum albumin – Ascites albumin
SAAG < 1.1g/dL
•
•
•
•
Nephrotic sx: TP >2.5g/dL
Peritoneal carcinomatosis: + cytology
Peritoneal TB
Pancreatitis: ascitic amylase >100, ascitic
PMN > 250cells/mm3
• Serositis
SAAG ≥ 1.1
•
•
•
•
•
•
•
CIRRHOSIS: TP <2.5g/dL
Alcoholic hepatitis
Massive hepatic mets
CHF: TP ≥ 2.5g/dL
Constrictive pericarditis
Budd-Chiari syndrome
Spontaneous bacterial peritonitis:
ascites PMN > 250cells/mm3
Helpful videos
• http://www.accessmedicine.com/videoPlayer.aspx?aid=5
10013108&searchStr=paracentesis
– Go to www.musc.edu/library
– Access medicine
– Harrison’s online video “Paracentesis”
• http://app.proceduresconsult.com/Learner/projects/Chec
klistDetails.aspx?ProcedureId=7&procSN=IM012&Video=1#
– Go to www.musc.edu/library
– Clinical resources
– Procedures consult
– Search paracentesis
References
1.
2.
3.
4.
5.
6.
7.
Maria A. Yialamas, Anna Rutherford, and Lindsay King. Abdominal
Paracentesis. Harrison’s Online
http://app.proceduresconsult.com/Learner/projects/ChecklistDetails.aspx?Pr
ocedureId=7&procSN=IM-012&Video=1#
Runyon BA, Montano AA, Akriviadis EA, Antillon MR, Irving MA,
McHutchison JG. The serum-ascites albumin gradient is superior to the
exudate-transudate concept in the differential diagnosis of ascites. Ann
Intern Med. 1992 Aug 1;117(3):215-20
Patel P, Ernst F, Gunnarsson C. Evaluation of hospital complications and
costs associated with using ultrasound guidance during abdominal
paracentesis procedures. J Med Econ. 2012; 15(1): 1-7
Thomsen TW, Shaffer RW, White B, Setnik GS: Paracentesis. N Engl J
Med. 2006;355:e21
Sandhu BS, Sanyal AJ: Management of ascites in cirrhosis. Clin Liver Dis.
2005;9:715-732
Runyon BA, AASLD Practice Guidelines Committee. Management of adult
patients with ascites due to cirrhosis: an update. Hepatology.
2009;49(6):2087