Paracentesis 

 Indications of Paracentesis

A. Diagnostic Paracentesis 

🔴 All patients with new-onset ascites
🔴 Any hospitalized patient with ascites

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

Anatomy – Where to Insert Needle?

Preferred Sites:

1. Left > Right Lower Quadrant (Most Common) lateral to the rectus abdominis muscle and 2 to 4 cm superomedial to the anterior superior iliac spine,midclavicular line(Avoid inferior epigastric artery)

BUT WHY -Left lower quadrant is preferred because the cecum because critically ill patients often have cecal distention.

2. Midline (2 cm below umbilicusthrough the linea alba)

Contraindications

 Absolute contraindications 

• Disseminated intravascular coagulation
• An acute abdomen requiring surgery

 Relative contraindications

• Pregnancy
• Ileus
• Intestinal obstruction
• Distended bladder
• Surgical scars
• The bowel may adhere to the abdominal wall near surgical scars; hence, the needle insertion location should be away from the scar to decrease the risk of bowel perforation. 
• Clotting derangements platelets < 20K ,nINR > 2.0) 
•  Clinicians can consider platelet transfusion before paracentesis if platelets are less than 20,000/µL.
• Administering FFP to patients before paracentesis is not indicated, as studies have demonstrated that LVP can be performed without a significant increase in bleeding-related complications and postprocedure transfusion despite an INR as high as 8.7

 Types of Paracentesis

Step-by-Step Procedure 

1️⃣ Preparation

• Consent
• Empty bladder(to reduce the risk of bladder injury.)
• Ultrasound marking (standard of care)

2️⃣ Position

• Supine with  head of the bed elevated at 30° to 45°. 

3️⃣ Sterile Prep

• 2% chlorhexidine gluconate and 70% isopropyl alcohol
• Local anesthesia (1% lignocaine) with 1:200,000 epinephrine

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 ~10 mL each,  (for SBP)

 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

Large Volume Paracentesis (LVP) & Albumin

If >5 L removed → Give albumin within 1 hour of LVP.

Dose:
8 g albumin per liter removed

Prevents:

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

Large Volume Paracentesis (LVP) provides only temporary (transient) symptomatic relief, as it does not address the underlying chronic liver disease responsible for ascites formation. Consequently, reaccumulation of ascitic fluid is common, often necessitating repeated procedures.

In patients with malignant ascites who require frequent therapeutic paracentesis, percutaneous placement of a tunneled peritoneal catheter is a safe and effective alternative. This approach allows for intermittent drainage at home, reducing hospital visits and improving patient comfort.

The Alfapump system is a novel, automated, implantable device developed for the management of refractory ascites.

Mechanism of Action

• Continuously transfers ascitic fluid from the peritoneal cavity → urinary bladder
• Fluid is then eliminated naturally via urination

Clinical Benefits

• Reduces the need for repeated LVP
• Improves quality of life
• Enhances nutritional status

Limitations / Contraindications

• Contraindicated in renal failure (risk of volume overload and worsening renal function)
• Hepatic encephalopathy: Patients may face difficulty managing the device, making its use challenging

 Complications

Immediate

• Bleeding(Most common)
• Bowel, bladder perforation
• Hypotension

Delayed

• Persistent leak of ascitic fluid from insertion site(Most common)
• Infection
• PICD

Rare but Serious

• Hemoperitoneum
• Inferior epigastric artery injury

REFERENCE

1.Kurapati R, Katta S, O’Rourke MC. Paracentesis. [Updated 2025 Sep 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK435998/

2.Irwin & Rippe’s INTENSIVE CARE MEDICINE Ninth Edition