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KEY POINTS
Paracentesis is a relatively safe procedure that can be performed in either the inpatient or outpatient setting.
Diagnostic paracentesis should be performed on any patient with newly diagnosed ascites or any patient with known ascites that has a change in clinical status.
Therapeutic “total paracentesis,” the removal of all of the ascites with albumin replacement, is a safe technique for the treatment of symptomatic ascites.
Coagulation testing need not be performed and correction of coagulation abnormalities prior to paracentesis is unnecessary.
A-2 probe ultrasound technique (low-frequency probe to find an optimal fluid pocket and high-frequency probe to evaluate the abdominal wall for vessels) should be used in all cases.
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Abdominal paracentesis is a procedure in which fluid is removed from the peritoneal cavity with a needle or cannula in patients with ascites. It is a relatively quick and safe procedure and can be done with a minimal amount of equipment as an outpatient procedure or at the bedside for inpatients. Now routinely used as an adjunct to paracentesis, point-of-care ultrasound is a simple procedure that confirms the presence of ascites. Proper analysis of fluid is invaluable in determining the etiology of ascites. The procedure can be done by any trained physician, surgeon, or a midlevel provider. At our institution we have a dedicated team of proceduralists and intensivists experienced in performing paracentesis using exclusively ultrasound guidance.
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The procedure can be done for therapeutic, diagnostic, or both purposes.
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Diagnostic: The procedure helps diagnose.
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The cause of a new-onset ascites or the status of preexisting ascites in patients who are admitted to the hospital for any reason. This is particularly important if there is evidence of infection, hepatic encephalopathy, fever, leukocytosis hypotension, and acute kidney injury.1
Spontaneous bacterial peritonitis where detection at an early stage and expedient initiation of antibiotics can lower mortality. Therefore, the procedure must be performed promptly in virtually all circumstances where a patient with known or newly discovered ascites sustains any change in clinical status. Delays that may occur due to lack of an experienced operator, unfounded concerns for the presence of coagulopathy, or unnecessary administration of blood products prior to paracentesis should be avoided. Analysis of the ascitic fluid may allow not only assessment of the likelihood of spontaneous bacterial peritonitis (SBP) but, with proper collection, identification of a specific microorganism and susceptibility testing to antibiotics guiding treatment in 90% of cases.
Secondary peritonitis when free fluid is present in peritoneal cavity from rupture or perforation of an abdominal organ. The total protein may be a key differentiating factor in this situation as it is generally low in SBP but may be normal or elevated in secondary causes.
Malignancy-related ascites (not to be confused with peritoneal carcinomatosis) may be seen with several tumors, including malignancies of the ovary, pancreas, colon, ...