Image 2 shows the same pocket magnified after the paracentesis catheter has been inserted. The catheter appears as a linear, hyperechoic structure. In all, 6 liters were safely drained off this particular patient, and he went upstairs quite pleased about his rapid weight loss, joking that he should be a contestant on “The Biggest Loser”.
PARACENTESIS: (Safest with real time US guidance) Indications
-Diagnostic: new ascites, r/o infected ascites
-Therapeutic: tense ascites, respiratory distress
-Uncooperative patient, scar or cellulitis at site, bowel
obstruction, pregnant, DIC, tPA in use
Relative: INR >1.5-5.0
-Most experts say tap is OK regardless of INR.
-Platelets < 50. Attempts to correct INR may cause more complications than the procedure itself.
-Decompress bladder, position HOB at 45-60° (bowel floats) then use US to find best pocket
-Use curved probe. Find and measure biggest fluid pocket (usually RLQ or LLQ) with no vessels or organs in way.
-Don’t reposition patient after ultrasound, as fluid may move. Avoid scars, veins & big spleen
-Use Z-puncture. Pull skin down 2 cm before inserting needle to prevent leakage from site afterwards
-SBP: > 250 PMNs, >1000 WBC, Serum-Ascitic Albumin Gradient < 1.1
-Exudative: Protein >3 or ratio >0.5. LDH >200 or ratio >0.6, specific gravity >1.016