Ideally all ascitic interventions should be ultrasound guided
Indications for ascitic tap (paracentesis)
To aid diagnosis of the cause of ascites or in the diagnosis or exclusion of SBP
A diagnostic paracentesis should be performed in all patients with new onset grade 2 or 3 ascites, and in all patients hospitalized for worsening of ascites or any complication of cirrhosis
Grade of ascites
Mild ascites only detectable by ultrasound
Moderate ascites evident by moderate symmetrical distension of abdomen
Restriction of sodium and diuretics
Large ascites with marked abdominal distension
Large volume paracentesis followed by treatment as for (2)
Equipment required for ascitic tap (paracentesis)
Dressing trolley & sharps bin
Sterile dressing pack
2% Chlorhexadine swabs
10mls of 1% or 2% Lidocaine
Orange (25G) needle (x1)
Green (19G) needle (x1)
10ml Syringe (x1)
20ml Syringe (x1)
with green (19G) needle (x1)
Blood culture bottles
Contraindications to ascitic tap (paracentesis)
Chose another site
Cautions – but not contraindications
Attempt to correct INR to <1.5 if possible.
Thrombocytopenia and coagulopathy is often present in liver disease and though it is a caution, it not a contraindication to paracentesis or drainage
The incidence of clinically significant bleeding is low; routine FFP or platelets is not indicated
Consent patient and explain procedure
Consent for infection, bleeding, pain, failure, damage to surrounding structures (especially bowel perforation – rare), leakage
Lie patient flat and examine clinically to confirm ascites
Ultrasound area for insertion
Aim for 1/3 to ½ of the way between the anterior superior iliac spine and the umbilicus avoiding vessels and scars
Procedure for ascitic tap (paracentesis)
Position the patient supine in the bed with their head resting on a pillow.
Select an appropriate point on the abdominal wall in the right or left lower quadrant, lateral to the rectus sheath. If a suitable site cannot be found with palpation and percussion consider using ultrasound to mark a spot.
Clean the site and surrounding area with 2% Chlorhexadine and apply a sterile drape.
Anaesthetise the skin with Lidocaine using the orange needle.
Anaesthetise deeper tissues using the green needle, aspirating as you insert the needle to ensure you are not in a vessel before infiltrating with lidocaine. Use a maximum of 10mls of Lidocaine.
Take a clean green needle and 20ml syringe and insert through the skin advancing and aspirating until fluid is withdrawn
Remove needle and apply sterile dressing
NEJM video on paracentesis
Samples in paracentesis
Microscopy, culture & sensitivities (be explicit if yeast or mycobacterium suspected)
Culture in blood culture bottles inoculated at the bedside
Automated WCC count (send EDTA sample)
Albumin, Protein, LDH, Glucose
Remember to send a serum albumin, LDH and glucose at the same time (or at least from the same day).
Special tests: Fluid amylase, Triglycerides, Bilirubin
Sent the largest sample
Samples can also be sent for immunology (RF, ANA) and TB culture if clinically indicated
In the event of failure
Seek senior help
Consider further imaging or aspiration in radiology
Top Tips for ascitic tap (paracentesis)
Always send the most fluid to cytology, especially if malignancy is suspected. The more fluid sent, the higher the diagnostic yield.
Never dispose of unused fluid, put it in an extra pot and add to the cytology sample.
If you want to gain a larger sample use a 50ml syringe to aspirate fluid
In patients with a thick abdominal wall a spinal needle can be used to infiltrate anaesthetic and check position.
If you aspirate blood when infiltrating an anaesthetic; stop, withdraw your needle, change position by 1-2cm and try again.