1 00:00:03,379 --> 00:00:07,400 This is a video in Clinical Medicine from the New England Journal of Medicine. 2 00:00:42,240 --> 00:01:03,159 many patients undergoing paracentesis will have baseline coagulopathy or thrombocytopenia however the incidence of clinically significant bleeding during paracentesis is extremely low and routine use of fresh frozen plasma or platelet concentrates is not recommended 3 00:01:03,159 --> 00:01:14,840 paracentesis should be avoided in patients with disseminated intravascular coagulation the paracentesis needle should not pass through sites of cutaneous infection 4 00:01:14,840 --> 00:01:31,680 visibly engorged subcutaneous veins surgical scars or abdominal wall hematomas extra caution should be used in pregnant patients and those with organomegaly small bowel obstructions or probable adhesions 5 00:01:31,680 --> 00:01:46,680 when available ultrasound guidance should be used to minimize the risk of intra-abdominal organ injury especially in patients who are overweight and those with multiple surgical scars 6 00:01:46,680 --> 00:01:59,420 there are various devices which are frequently assembled in prepackaged kits that can be used to perform paracentesis you should be familiar with the specific devices available at your institution 7 00:01:59,420 --> 00:02:10,400 For sterile preparation and administration of anesthesia, you will need a skin cleansing agent, sterile gauze, sterile gloves and drape, and a face shield. 8 00:02:11,120 --> 00:02:21,439 You will also need a skin marking pen, 1 or 2% lidocaine, a 10 mL syringe, and a 22 or 25 gauge needle. 9 00:02:21,439 --> 00:02:31,800 For a collection of acidic fluid, you will need an over-the-needle catheter device, a 60-milliliter syringe, and high-pressure drainage tubing. 10 00:02:32,659 --> 00:02:38,939 You will also need specimen tubes, large evacuated containers, and a sterile occlusive dressing. 11 00:02:40,240 --> 00:02:46,419 In this video, we will demonstrate the use of a paracentesis-specific needle and catheter assembly. 12 00:02:47,379 --> 00:02:51,900 This device has a safety mechanism with a retractable blunt obturator. 13 00:02:52,719 --> 00:02:55,740 When pressure is applied to the distal end of the device, 14 00:02:55,740 --> 00:03:01,439 the obturator retracts and the bevel of the needle is exposed, allowing penetration of the tissues. 15 00:03:02,560 --> 00:03:07,680 An indicator at the top of the device will turn red whenever the obturator is retracted. 16 00:03:08,340 --> 00:03:12,319 Once the peritoneal cavity is entered, the obturator redeploys. 17 00:03:12,319 --> 00:03:17,319 This safety mechanism theoretically reduces the risk of organ injury. 18 00:03:17,319 --> 00:03:23,319 Additional advantages of paracentesis-specific devices include 19 00:03:23,319 --> 00:03:28,319 multiple distal drainage holes, which facilitate rapid fluid removal, 20 00:03:28,319 --> 00:03:33,319 and a pigtail mechanism that curves the distal end of the catheter 21 00:03:33,319 --> 00:03:36,319 away from intra-abdominal structures during advancement. 22 00:03:36,319 --> 00:03:40,319 If such devices are not available at your institution, 23 00:03:40,319 --> 00:03:43,960 standard 18-gauge intravenous catheters may be used. 24 00:03:44,780 --> 00:03:46,979 The technique described in the following section 25 00:03:46,979 --> 00:03:50,000 is applicable to all over-the-needle catheters. 26 00:03:54,280 --> 00:03:58,020 Explain the procedure to the patient and obtain informed consent. 27 00:03:58,740 --> 00:04:02,599 Risks of bleeding, infection, intra-abdominal organ injury, 28 00:04:02,900 --> 00:04:05,419 and post-procedure hypotension should be discussed. 29 00:04:06,319 --> 00:04:10,319 Position the patient supine in the bed with the head slightly elevated. 30 00:04:11,080 --> 00:04:16,339 Recommended sites of needle insertion are 2 cm below the umbilicus in the midline 31 00:04:16,339 --> 00:04:19,480 and either the left or right lower quadrants. 32 00:04:20,279 --> 00:04:22,139 If a lower quadrant approach is used, 33 00:04:22,560 --> 00:04:25,579 confirm that the entry site is lateral to the rectus sheath 34 00:04:25,579 --> 00:04:28,699 to avoid puncturing the inferior epigastric artery. 35 00:04:29,560 --> 00:04:32,060 If the subumbilical approach is used, 36 00:04:32,060 --> 00:04:34,500 the bladder should be emptied before the procedure. 37 00:04:35,560 --> 00:04:38,459 If available, bedside ultrasound should be used 38 00:04:38,459 --> 00:04:42,220 to find an appropriate location that contains acidic fluid 39 00:04:42,220 --> 00:04:45,519 but is devoid of loops of bowel or solid organs. 40 00:04:46,259 --> 00:04:49,019 Mark the site of needle insertion with a skin marking pen. 41 00:04:50,339 --> 00:04:52,360 Paracentesis is a sterile procedure. 42 00:04:53,220 --> 00:04:55,540 Sterile gloves and a face shield are required. 43 00:04:56,160 --> 00:04:58,220 The use of a sterile gown is optional. 44 00:04:58,939 --> 00:05:02,899 Prepare the site with an antiseptic solution and then apply a sterile drape. 45 00:05:03,779 --> 00:05:06,939 Using a 22 or 25 gauge needle, 46 00:05:06,939 --> 00:05:12,259 anesthetize the superficial skin with a wheel of local anesthetic such as lidocaine. 47 00:05:12,800 --> 00:05:18,259 Continue to anesthetize the deeper tissues in the anticipated tract of the paracentesis catheter, 48 00:05:18,740 --> 00:05:22,040 intermittently pulling back on the syringe every 2 to 3 millimeters. 49 00:05:23,060 --> 00:05:25,879 Once peritoneal fluid begins to fill the syringe, 50 00:05:25,879 --> 00:05:31,420 inject additional anesthetic to anesthetize the highly sensitive parietal peritoneum. 51 00:05:32,319 --> 00:05:36,660 A total of 5 to 10 milliliters of lidocaine is generally used. 52 00:05:36,939 --> 00:05:45,639 Begin by making a small puncture in the skin with either a scalpel or a large gauge needle 53 00:05:45,639 --> 00:05:48,800 to facilitate advancement of the paracentesis catheter. 54 00:05:49,660 --> 00:05:52,800 Next, advance the catheter through the epidermis. 55 00:05:53,379 --> 00:05:56,699 In this video, we will demonstrate an angular entry technique 56 00:05:56,699 --> 00:06:03,680 in which the cutaneous site of insertion does not directly overlie the site of penetration into the peritoneal cavity. 57 00:06:04,519 --> 00:06:07,899 Alternatively, a Z-tract technique may be used. 58 00:06:07,899 --> 00:06:16,759 In this method, the cutaneous tissues are pulled 2 cm caudad prior to needle insertion and advancement through the peritoneum. 59 00:06:17,420 --> 00:06:24,139 When the catheter is withdrawn at the end of the procedure, the cutaneous entry site will retract to its original position. 60 00:06:25,100 --> 00:06:31,759 Both techniques ensure that the cutaneous and peritoneal insertion sites do not directly overlie each other, 61 00:06:32,199 --> 00:06:36,579 theoretically minimizing the risk of an acidic fluid leak following the procedure. 62 00:06:36,579 --> 00:06:42,579 Intermittently pull back on the plunger as you continue to advance the needle through the subcutaneous tissue. 63 00:06:42,579 --> 00:06:46,579 Bedside ultrasound may be used to confirm proper placement. 64 00:06:46,579 --> 00:06:51,579 You may feel a sudden loss of resistance when the needle pierces the peritoneum. 65 00:06:51,579 --> 00:06:56,579 Immediately stop advancement once the acidic fluid begins to fill the syringe. 66 00:06:56,579 --> 00:07:03,579 Next, guide the plastic catheter over the needle and into the peritoneal cavity, and then remove the needle. 67 00:07:03,579 --> 00:07:23,339 if a diagnostic sample is required attach a large syringe to the catheter and aspirate thirty to sixty milliliters of fluid for analysis for therapeutic large-volume paracentesis attach the high-pressure tubing to the end of the catheter and then to an evacuated container 68 00:07:23,339 --> 00:07:39,600 further containers may be used for collection of fluid if necessary blood pressure and heart rate should be monitored during large volume paracentesis once the desired quantity of fluid has been removed withdraw the catheter and apply a bandage 69 00:07:39,600 --> 00:07:55,149 aspirated fluid should be immediately placed into appropriate specimen tubes a tube without additives should be sent for chemical analysis of albumin and total protein concentrations 70 00:07:55,149 --> 00:08:12,209 an edta tube should be sent for evaluation of cell count and differential blood culture bottles should be inoculated at the bedside using aseptic technique if spontaneous bacterial peritonitis or other infection is a diagnostic concern 71 00:08:12,209 --> 00:08:24,769 specimens for other tests such as cytology or mycobacterial culture may be sent depending on the clinical scenario and are discussed in further detail in the accompanying written supplement 72 00:08:24,769 --> 00:08:30,490 Analysis of the fluid begins with the determination of the serum ascites albumin gradient. 73 00:08:31,589 --> 00:08:37,929 Gradients higher than 1.1 grams per deciliter indicate that the ascites is due to portal hypertension. 74 00:08:39,110 --> 00:08:47,330 Gradients less than 1.1 grams per deciliter suggest other causes, such as cancer, infection, or pancreatitis. 75 00:08:47,330 --> 00:08:57,320 Post-parasynthesis circulatory dysfunction may occur after large-volume parasynthesis 76 00:08:57,320 --> 00:09:03,840 and may lead to hypotension, hyponatremia, renal failure, and shortened survival. 77 00:09:04,799 --> 00:09:08,299 Although the use of albumin as a plasma expander is controversial, 78 00:09:08,299 --> 00:09:12,460 its use is recommended if more than 5 liters of fluid have been removed. 79 00:09:13,480 --> 00:09:17,500 Other complications of parasynthesis include localized infection, 80 00:09:17,500 --> 00:09:24,940 abdominal wall hematomas, and persistent ascites fluid leak. More serious complications are rare 81 00:09:24,940 --> 00:09:31,879 and include hemorrhage, intra-abdominal organ injury, and inferior epigastric artery puncture.