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Clinical Procedures - Abdominal Paracentesis (Drainage)
Indications
• To relieve symptoms in patients with tense ascites
• Refractory ascites in patients with cirrhosis of the liver
• Malignant ascites.
Contraindications
• Acute abdomen that requires surgery
• Pregnancy
• Intestinal obstruction
• Grossly distended urinary bladder
• Superficial infection (cellulitis) at the potential puncture site
• Hernia at the potential puncture site
• Caution is needed in the presence of omental or peritoneal metastatic disease. In these cases, drainage is often performed under imaging guidance by a radiologist.
Risks
• Haemodynamic instability, especially in cirrhotic patients; avoided by albumin replacement. (Usually 100mL 20% human albumin solution IV for every 2.5L fluid drained check local protocols with the Gastroenterology Department)
• Renal dysfunction (in those with abnormal baseline renal function. May need to withhold diuretics and limit drain volume to 5L)
• Wound infection
• Bleeding
• Perforation of bowel and bladder
• Abdominal wall hematoma.
Procedure Tips
• Avoid any area of skin which has a scar or engorged veins to minimize complications
• Low-grade coagulopathy is common in cirrhotic patients and use of fresh frozen plasma and platelets is not routinely recommended; seek senior advice
• Fluid leak can be minimized by the '-track' technique, moving the skin and subcutaneous tissue while insertion of drain, creating a zigzag path
• If no aspirate is obtained despite multiple attempts, liaise with Radiology and request an ultrasound and marking of a suitable site for aspiration.
Alternatively, ask the Radiology Department to insert the drain under ultrasound guidance.
The procedure below relates to a non-locking drainage kit from Rocket Medical -the essence is the same for other catheter kits although minor details may differ. You should refer to the kit's instructions.
Equipment
• Rocket abdominal catheter pack (catheter sleeve, puncture needle, and adaptor clamp)
• Catheter bag and stand
• 1 × 25G (orange) needle
• 1 x 21G (green) needle
• 3 x 10mL syringes
• 5mL 1% lidocaine
• lodine or antiseptic solution
• Sterile pack (including gloves, cotton balls, and bowl)
• Suitable adhesive dressing
• Scalpel/blade.
Procedure
• Introduce yourself, confirm the identity of the patient, explain the procedure, and obtain informed consent
• Ensure that the patient has emptied their bladder
• Position the patient lying supine or semi-recumbent
• Percuss the extent of the ascitic dullness
• Mark your chosen spot in the region of the left iliac fossa within the area of dullness:
• Double-check clinical examination and imaging, if available.
If splenomegaly is present, right-sided drainage is recommended
• Wash hands and put the sterile gloves on
• Clean the area thoroughly with antiseptic
• Infiltrate the skin and subcutaneous tissues with lidocaine via the orange needle and 10mL syringe
• Attach the green needle to another 10mL syringe and insert into the abdomen, perpendicular to the skin. Advance the needle as you aspirate until fluid is withdrawn
• Prepare the catheter kit straighten the curled catheter using the plastic covering sheath provided
• Take the needle provided in the pack and pass through the sheath such that the needle bevel is directed along inside the curve of the catheter continue until the needle protrudes from the catheter tip
• Remove the plastic covering sheath
• Attach a 10mL syringe to the end of the catheter
• Make a small incision in the skin using the scalpel
• Grasp the catheter needle -10cm above the distal end and, with firm but controlled pressure, push the needle through the abdominal wall to ~3.5cm deep, aspirating with the syringe
• Aspiration of ascitic fluid confirms entry to the abdominal cavity
• Disengage needle from the catheter hub and advance catheter until the suture disc is flat against the skin
• Withdraw needle
• Connect adaptor-clamp to the catheter hub and securely attach the rubber portion of the clamp into a standard drainage catheter bag
• Secure the catheter to the abdomen using a suitable adhesive dressing
• Ensure the clamp is open to allow fluid to drain.
Documentation
• Date, time, indication, informed consent obtained
• Type and amount of local anaesthetic used
• Site of drain
• Aseptic technique used?
• How many passes?
• Volume and colour of fluid obtained
• Any immediate complications
• Document the required albumin replacement (if appropriate) and when the catheter should be clamped.
• Signature, printed name and contact details.
Indications
• To relieve symptoms in patients with tense ascites
• Refractory ascites in patients with cirrhosis of the liver
• Malignant ascites.
Contraindications
• Acute abdomen that requires surgery
• Pregnancy
• Intestinal obstruction
• Grossly distended urinary bladder
• Superficial infection (cellulitis) at the potential puncture site
• Hernia at the potential puncture site
• Caution is needed in the presence of omental or peritoneal metastatic disease. In these cases, drainage is often performed under imaging guidance by a radiologist.
Risks
• Haemodynamic instability, especially in cirrhotic patients; avoided by albumin replacement. (Usually 100mL 20% human albumin solution IV for every 2.5L fluid drained check local protocols with the Gastroenterology Department)
• Renal dysfunction (in those with abnormal baseline renal function. May need to withhold diuretics and limit drain volume to 5L)
• Wound infection
• Bleeding
• Perforation of bowel and bladder
• Abdominal wall hematoma.
Procedure Tips
• Avoid any area of skin which has a scar or engorged veins to minimize complications
• Low-grade coagulopathy is common in cirrhotic patients and use of fresh frozen plasma and platelets is not routinely recommended; seek senior advice
• Fluid leak can be minimized by the '-track' technique, moving the skin and subcutaneous tissue while insertion of drain, creating a zigzag path
• If no aspirate is obtained despite multiple attempts, liaise with Radiology and request an ultrasound and marking of a suitable site for aspiration.
Alternatively, ask the Radiology Department to insert the drain under ultrasound guidance.
The procedure below relates to a non-locking drainage kit from Rocket Medical -the essence is the same for other catheter kits although minor details may differ. You should refer to the kit's instructions.
Equipment
• Rocket abdominal catheter pack (catheter sleeve, puncture needle, and adaptor clamp)
• Catheter bag and stand
• 1 × 25G (orange) needle
• 1 x 21G (green) needle
• 3 x 10mL syringes
• 5mL 1% lidocaine
• lodine or antiseptic solution
• Sterile pack (including gloves, cotton balls, and bowl)
• Suitable adhesive dressing
• Scalpel/blade.
Procedure
• Introduce yourself, confirm the identity of the patient, explain the procedure, and obtain informed consent
• Ensure that the patient has emptied their bladder
• Position the patient lying supine or semi-recumbent
• Percuss the extent of the ascitic dullness
• Mark your chosen spot in the region of the left iliac fossa within the area of dullness:
• Double-check clinical examination and imaging, if available.
If splenomegaly is present, right-sided drainage is recommended
• Wash hands and put the sterile gloves on
• Clean the area thoroughly with antiseptic
• Infiltrate the skin and subcutaneous tissues with lidocaine via the orange needle and 10mL syringe
• Attach the green needle to another 10mL syringe and insert into the abdomen, perpendicular to the skin. Advance the needle as you aspirate until fluid is withdrawn
• Prepare the catheter kit straighten the curled catheter using the plastic covering sheath provided
• Take the needle provided in the pack and pass through the sheath such that the needle bevel is directed along inside the curve of the catheter continue until the needle protrudes from the catheter tip
• Remove the plastic covering sheath
• Attach a 10mL syringe to the end of the catheter
• Make a small incision in the skin using the scalpel
• Grasp the catheter needle -10cm above the distal end and, with firm but controlled pressure, push the needle through the abdominal wall to ~3.5cm deep, aspirating with the syringe
• Aspiration of ascitic fluid confirms entry to the abdominal cavity
• Disengage needle from the catheter hub and advance catheter until the suture disc is flat against the skin
• Withdraw needle
• Connect adaptor-clamp to the catheter hub and securely attach the rubber portion of the clamp into a standard drainage catheter bag
• Secure the catheter to the abdomen using a suitable adhesive dressing
• Ensure the clamp is open to allow fluid to drain.
Documentation
• Date, time, indication, informed consent obtained
• Type and amount of local anaesthetic used
• Site of drain
• Aseptic technique used?
• How many passes?
• Volume and colour of fluid obtained
• Any immediate complications
• Document the required albumin replacement (if appropriate) and when the catheter should be clamped.
• Signature, printed name and contact details.
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