HWN Suggests

Paracentesis: are you stabbing in the dark?

here is how I do it – no evidence, just experience….

• Do a scout scan to identify the deepest pocket of fluid and where the organs are that you want to miss- liver, spleen, bowel…
• Pick a spot – I don’t mind if it is left or right, as long as it is clear on the US
• Roll the patient with a pillow under one buttock (procedure side-down) and leave them for 15 minutes
• Rescan to confirm you have a clear space, measure the depth to the peritoneum and the depth of fluid beyond that.
• Prep / aseptic technique. Inject some local with adren. into your spot and infiltrate to the peritoneum
• I use a suprapubic catheter kit, but a central line…

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Nonetheless, I firmly believe that performing paracentesis and diagnosing SBP should ride high on our list of priorities. A diagnostic tap takes all of a few minutes, no more than an ultrasound-guided IV, for which we're called on at an alarmingly increasing rate. Early diagnosis of SBP matters not only because of the high mortality associated with it (nearly 40% in most cohorts) but also because early ED intervention makes a difference.

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Have the patient empty his or her bladder, then have them lie upright with the head of the bed elevated at 45-60°. This angle allows the bowel to float up and the ascites to collect in the lower abdomen. Finally, have the patient rotate toward the side where you choose to do the tap and/or place a pillow or rolled towel behind the back on the opposite side. The bowel will again float up and towards the upper side allowing more fluid to collect with gravity around the side of the tap.

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