Paracentesis 

1️⃣ Definition

Paracentesis is a bedside procedure in which ascitic fluid is removed from the peritoneal cavity for:

• Diagnostic purposes
• Therapeutic relief
• Refractory ascites management

 2️⃣ Indications of Paracentesis

A. Diagnostic Paracentesis 

🔴 All patients with new-onset ascites
🔴 Any hospitalized patient with ascites
🔴 Clinical deterioration (fever, shock, AKI, encephalopathy)

Why? → To rule out:

• Spontaneous bacterial peritonitis
• Secondary bacterial peritonitis
• Malignancy
• Tuberculosis

B. Therapeutic Paracentesis

• Tense ascites
• Respiratory compromise
• Abdominal compartment syndrome
• Refractory ascites
• Pain

4️⃣ Anatomy – Where to Insert Needle?

Preferred Sites:

 Left Lower Quadrant (Most Common) BUT WHY -Left lower quadrant is preferred because the cecum on the right is large and mobile, increasing perforation risk, whereas the descending colon on the left is fixed and less distensible, making LLQ safer

• 2–3 cm above and medial to ASIS
• Avoid inferior epigastric artery

 Midline (2 cm below umbilicus)

• Only if no surgical scar

5️⃣ Contraindications

Absolute

❌ None (Life-saving in tense ascites)

Relative

• Severe thrombocytopenia (<20,000)
• DIC
• Overlying cellulitis
• Massive bowel distension
• Pregnancy

🔴 Important Exam Point:
Coagulopathy in cirrhosis is NOT a contraindication.
Routine FFP is NOT recommended.

6️⃣ Types of Paracentesis

7️⃣ Step-by-Step Procedure (ICU Practical)

1️⃣ Preparation

• Consent
• Empty bladder
• Ultrasound marking (standard of care)

2️⃣ Position

• Supine
• Head elevated 30–45°

3️⃣ Sterile Prep

• Chlorhexidine
• Local anesthesia (1% lignocaine)

4️⃣ Needle 20–22 gauge needle Insertion

• Z-track technique (reduces leak)
• Advance while aspirating

5️⃣ Fluid Collection

• Diagnostic tubes:
• EDTA (cell count)
• Plain (biochemistry)
• Blood culture bottle (for SBP)

8️⃣ Ascitic Fluid Analysis 

A. SAAG (Serum Ascites Albumin Gradient)

SAAG = Serum albumin – Ascitic albumin

≥ 1.1 g/dL → Portal Hypertension

• Liver cirrhosis
• Congestive heart failure

< 1.1 g/dL → Non-Portal

• Peritoneal carcinomatosis
• Tuberculosis

B. Cell Count

🔴 SBP Diagnosis

PMN ≥ 250 cells/mm³
= Spontaneous bacterial peritonitis

Even if culture negative → Treat!

C. Other Tests

9️⃣ Large Volume Paracentesis (LVP) & Albumin

🔴 If >5 L removed → Give albumin

Dose:
8 g albumin per liter removed

Prevents:

• Paracentesis-induced circulatory dysfunction (PICD)
• AKI
• Hyponatremia

🔟 Complications

Immediate

• Bleeding
• Bowel perforation
• Hypotension

Delayed

• Persistent leak
• Infection
• PICD

Rare but Serious

• Hemoperitoneum
• Inferior epigastric artery injury