PROCEDURE Paracentesis (Perform) 115 Eleanor Fitzpatrick PURPOSE: Abdominal paracentesis is performed to remove fl uid from the peritoneal cavity for diagnostic or therapeutic purposes.

PREREQUISITE NURSING from the serum albumin value. This calculation differenti- KNOWLEDGE ates portal hypertensive from nonportal hypertensive . 2,3,5,9,11 • Knowledge of anatomy and physiology of the is • Paracentesis is contraindicated in patients with an acute important to avoid unexpected outcomes. abdomen, who need immediate . Coagulopathy • Intestines and bladder lie immediately beneath the abdom- should preclude paracentesis only in the case of clinically inal surface. evident fi brinolysis or clinically evident disseminated • Large volumes of ascitic fl uid tend to fl oat in the air-fi lled intravascular coagulation.3,10 Absolute contraindications bowel toward the midline, where the bowel may be per- include an acute abdomen, an uncooperative patient, and forated during the procedure. disseminated intravascular coagulopathy. Relative contra- • The cecum is relatively fi xed and is much less mobile than indications include coagulopathy, abdominal adhesions, the ; therefore bowel perforations are more infected abdominal wall at the entry site, distended bowel frequent in the right lower quadrant than in the left. or bladder, and pregnancy.15 • Peritoneal fl uid is normally straw-colored serous fl uid • Caution should be used when paracentesis is performed secreted by the cells of the . Grossly bloody in patients with severe bowel distention, previous abdomi- fl uid in the abdomen is abnormal. nal surgery (especially pelvic surgery), pregnancy (use • The peritoneal fl uid collected is used in evaluation and open technique after fi rst trimester), distended bladder that diagnosis of ascites, acute abdominal conditions such as cannot be emptied with a Foley catheter, or obvious infec- or , and blunt or penetrating trauma tion at intended site of insertion (cellulitis or abscess). to the abdomen. • The insertion site should be midline one third the distance • Therapeutic paracentesis is used to reduce intraabdominal from the umbilicus to the symphysis, or 2 to 3 cm below and diaphragmatic pressures, to relieve dyspnea and respi- the umbilicus (Fig. 115-1). An alternate position is a point ratory compromise, and to prevent formation one third the distance from the umbilicus to the anterior and diaphragmatic rupture.2,8,11 These complications are iliac crest (left side preferred especially in the obese seen in patients with tense, refractory ascites and failed patient or in those requiring removal of large volumes of medical interventions such as sodium restriction and fl uid).2,10,11,13 diuresis.2,3,5,11,15 • Ultrasound scan can be used before paracentesis to locate • Cirrhosis is the most common cause of ascites formation. fl uid and during the procedure to guide insertion of However, ascitic fl uid is produced as a result of a variety catheter. of other conditions.2,5,7,10 These conditions may include • If ascitic fl uid is diffi cult to localize with physical exami- interference in venous return because of , nation because of obesity or other conditions, ultrasound constrictive pericarditis, or tricuspid valve insuffi ciency; is effective in identifying the fl uid and critical structures obstruction of fl ow in the vena cava or portal vein; distur- which are to be avoided during the procedure. 10,12 Endo- bance in electrolyte balance, such as sodium retention; scopic transgastric ultrasound scan has also been used in depletion of plasma proteins because of nephrotic syn- the diagnosis of malignant ascites.2,13 drome or starvation; lymphoma, leukemia, or neoplasms • A semipermanent catheter or a shunt may be an option for that involve the or mediastinum; ovarian malignant patients with rapidly reaccumulating ascites. 2,3,10 disease; and chronic pancreatitis. • When large-volume paracentesis (> 5 L) is performed in • Analysis of the ascitic fl uid can determine the cause of patients with cirrhosis and other disorders, the infusion of ascites. A serum-to-ascites albumin gradient should be albumin, (6 to 8 g/L) of fl uid removed, may prevent the calculated by subtracting the ascitic fl uid albumin level onset of circulatory compromise associated with massive fl uid shifting.3,9–11,15 Albumin administration may be effec- This procedure should be performed only by physicians, advanced tive in preventing paracentesis-induced circulatory dys- practice nurses, and other healthcare professionals (including critical care function, the most common complication after the 13–15 nurses) with additional knowledge, skills, and demonstrated competence per procedure. Albumin infusion is recommended with professional licensure or institutional standard. large-volume paracentesis.1

1030 115 Paracentesis (Perform) 1031

PATIENT AND FAMILY EDUCATION Linea alba • Explain the indications, procedure, and risks to the patient and family. Rationale: Explanation may decrease patient Umbilicius anxiety and encourages patient and family cooperation and understanding of the procedure. • Explain the patient ’ s role in assisting with the procedure and postprocedure care. Rationale: Patient cooperation during and after the procedure is elicited. • Explain the to report, such as fever, 2 2 , decreased urine output, bleeding, and leakage of fl uid from surgical wound site. Rationale: 1 Unexpected outcomes may not manifest themselves for a period of time after the procedure.

Anterior PATIENT ASSESSMENT AND superior PREPARATION iliac spine Patient Assessment Figure 115-1 Preferred sites for paracentesis: 1, Primary site is infraumbilical in midline through linea alba. 2, Preferred alternate • Obtain the medical history and perform a review of (lateral rectus) site is in either lower quadrant, approximately 4 to systems for abdominal injury, major gastrointestinal 5 cm cephalad and medial to the anterior superior iliac spine. (From pathology, liver disease, and portal hypertension. Ratio- Roberts JR: Roberts and Hedges’ clinical procedures in emergency nale: Certain conditions of the gastrointestinal tract may medicine, ed 6, Philadelphia, 2014, Saunders.) be diagnosed and treated with paracentesis. Contraindica- tions to paracentesis may be identifi ed. • Identify the presence of any allergies to medication or other substances. Rationale: Patients may have allergies to skin preparations or anesthetics used before the inva- EQUIPMENT sive procedure is performed. Identifi cation assists the practitioner in choosing the most appropriate skin prepa- • Commercially prepared paracentesis kit if available ration and anesthetic. • Nonsterile gloves, sterile gloves, mask, gown • Assess respiratory status (i.e., rate, depth, excursion, gas • Antiseptic solution (e.g., 2% chlorhexidine-based preparation) exchange, use of accessory muscles, pulse oximetry). • Sterile marking pen Rationale: Paracentesis may be indicated to decrease the • Sterile towels or sterile drape work of breathing. • Local anesthetic for injection: 1% or 2% lidocaine with • Obtain baseline vital signs. Rationale: Hypotension and epinephrine dysrhythmias may occur with rapid changes in intraab- • 5- or 10-mL syringe with 21- or 25-gauge needle for dominal pressure. anesthetic • Obtain baseline pain assessment. Rationale: Changes in • Trocar with stylet, needle (16-, 18- or 20-gauge), or angio- level of pain during or after the procedure may be an catheter, depending on abdominal wall thickness indicator of complications. 1 • 25- or 27-gauge 1 2 -inch needle • Obtain baseline fl uid and electrolyte status. Rationale: • 20- or 22-gauge spinal needles Removal of peritoneal fl uid may cause compartment shift- • 20-mL syringe for diagnostic tap ing of intravascular volume, electrolytes, and proteins, • 50-mL syringe if using stopcock technique leading to a decreased circulating volume. • Four sterile tubes for specimens • Assess bowel or bladder distention. Rationale: Distension • Scalpel and No. 11 knife blade increases the risk for bowel or bladder perforation during • Three-way stopcock the procedure. • Sterile 1-L collection bottles with connecting tubing • Examine the abdomen, including assessment of abdomi- • Nylon skin suture material on cutting needle (4-0 or 5-0) nal girth, fl uid wave, and ; mark land- and needle holder marks as needed. Rationale: Knowledge of abdominal • Mayo scissors and straight scissors landmarks and an understanding of the amount of fl uid • Four to six sterile 4 × 4 gauze pads present are helpful in determining amount to drain as well • Sterile gauze dressing with tape or adhesive strip as where to best insert the catheter. Additional equipment, to have available as needed, includes • Obtain coagulation study results (i.e., prothrombin time, the following: partial thromboplastin time, and platelets). Rationale: • Soft wrist restraints Abnormal clotting may increase the risk for bleeding • Stoma bag during and after the procedure, although this complication • Ultrasound equipment is rare.2,10 Therapy may be necessary to correct clotting 1032 Unit IV Gastrointestinal System

abnormalities before the procedure, particularly if the • Obtain plain and upright radiographs of the abdomen international normalized ratio is over 2.5.10,11,13 before the procedure is performed. Rationale: Air is intro- duced during the procedure and may confuse the diagnosis Patient Preparation later. • Verify that the patient is the correct patient using two • Perform a preprocedure verifi cation and time out, if non- identifi ers. Rationale: Before performing a procedure, the emergent. Rationale: Ensures patient safety. nurse should ensure the correct identifi cation of the patient • Check that all relevant documents and studies are avail- for the intended intervention. able before the procedure is started. Rationale: This • Ensure that the patient understands preprocedural infor- measure ensures that the correct patient receives the mation. Answer questions as they arise, and reinforce correct procedure. information as needed. Rationale: Understanding of pre- • Place the patient in the supine position (may tilt to side of viously taught information is evaluated and reinforced. collection slightly for improved fl uid positioning). Ratio- • Obtain a written informed consent form. Rationale: Para- nale: Fluid accumulates in the dependent areas. centesis is an invasive procedure that requires signed • If the patient has altered mental status, soft wrist restraints informed consent. may be needed. Rationale: The patient must not move his • Decompress the bladder either by having the patient void or her hands into the sterile fi eld once it has been or by inserting a Foley catheter. Rationale: A distended established. bladder increases the risk for bladder perforation during the procedure.

Procedure for Performing Paracentesis Steps Rationale Special Considerations 1 . HH 2 . PE 3. Prepare equipment and sterile fi eld. Provides a sterile fi eld to Maintain aseptic technique. Label all medications, medication decrease risk for infection containers (e.g., syringes, medicine cups, basins), and other solutions that are to be used during the procedure. 4. With the patient in the supine position, Determines correct site for Avoid the rectus muscle because of determine the site for trocar insertion. trocar placement. An alternate increased risk for hemorrhage from Site should be midline one-third the position, frequently chosen in epigastric vessels; surgical scars distance from the umbilicus to the obese patients or when large because of increased risk for symphysis (2–3 cm below the volumes of fl uid are to be perforation caused by adhesion of umbilicus; see Fig. 115-1 ). removed, is a point one third bowel to the wall of the the distance from the peritoneum; and upper quadrants umbilicus to the anterior iliac because of the possibility of crest (left side preferred). undetected .2,13 5. Cleanse the insertion site with Reduces risk for infection. Allergies should be identifi ed before antiseptic solution (e.g., 2% a skin preparation product is chlorhexidine-based preparation.4,6 chosen. (Level C * ) Use sterile technique. 6. Wash hands and apply sterile gloves Reduces transmission of and sterile gown. microorganisms and body secretions. 7. Apply sterile drapes to outline the area Provide sterile fi eld to decrease to be tapped. risk for infection.

* Level C: Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results. 115 Paracentesis (Perform) 1033

Procedure for Performing Paracentesis—Continued Steps Rationale Special Considerations 8. Inject the area with local anesthetic Local anesthesia minimizes pain Usually 1% lidocaine is used, but (lidocaine with epinephrine preferred). and discomfort. Epinephrine 0.5% lidocaine with 1 : 200,000 Initially infi ltrate the skin and helps eliminate unwanted epinephrine has been shown to subcutaneous tissues in a abdominal wall bleeding and provide equivalent anesthetic effect circumferential wheel; then direct false-positive results. as 1% lidocaine with 1 : 100,000 needle perpendicular to the skin and epinephrine. The maximum dosage infi ltrate the peritoneum. is generally accepted to be 5 mg/kg of 1% plain lidocaine and 7 mg/kg of 1% lidocaine with epinephrine.16 Assess for anesthesia of the area. Resistance is felt as the needle perforates the peritoneum. 9. With the No. 11 blade and scalpel holder, Promotes easier insertion of the If lavage is necessary, the opening is create a skin incision large enough to catheter. large enough to thread the lavage allow threading a 3- to 5-mm catheter. catheter. 10. Insert an 18-gauge needle attached to a Provides access to peritoneal A small pop is felt as the needle 20- or 50-mL syringe through the fl uid for evacuation. Slight advances through the anterior and anesthetized tract into the peritoneum. suction is applied to indicate posterior muscle fascia and enters The needle is inserted through the when the peritoneum is the peritoneum. small stab wound created as noted in entered and if a blood vessel Step 9. The stab wound should be is entered. made at the midline below the Grasping the needle as it is umbilicus. Apply slight suction to the advanced prevents accidental syringe as it is advanced. Grasp the thrusting into the abdomen needle close to the skin as it is and possible viscus advanced. perforation. 11. Once in the cavity, direct the needle at Removes fl uid for laboratory Usually, diagnostic tests are ordered a 60-degree angle toward the center of analysis. dependent on the patient ’ s status the pelvic hollow. When fl uid returns, and reason for paracentesis. 2 fi ll the syringe ( Fig. 115-2 ). A fl exible Tests may include the following: tube catheter/drain can be thread into the 1: lactate dehydrogenase, glucose, abdominal cavity over the needle and albumin; tube 2: total protein, left in place if needed. specifi c gravity; tube 3: cell count and differential; tube 4: additional tests as needed. If there is suspicion of infection: gram stain, acid-fast bacillus stain, bacterial and fungal cultures, amylase, and triglyceride tests may be performed.2,10,13 Also, send a specimen for cytology if malignancy is suspected.10 12. Attach syringes or stopcock and tubing Initiates therapy. Monitor the amount of fl uid removed. and gently aspirate or siphon fl uid via Removal of large amounts of fl uid gravity or vacuum into the collection ( > 5 L) may cause hypotension.5,13,15 device. Drains may be left in and If large volume paracentesis is allowed to drain for 6–12 hours.11,13 performed (> 5–6 L) an albumin (Level E * ) infusion of 6–8 g/L of fl uid removed improves survival and is recommended to prevent circulatory dysfunction.1,3,5,10,13,15 (Level A * )

* Level A: Meta-analysis of quantitative studies or metasyn thesis of qualitative studies with results that consistently support a specifi c action, intervention, or treatment (including systematic review of randomized controlled trials). * Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional orga nizational standards without clinical studies to support recommendations.

Procedure continues on following page 1034 Unit IV Gastrointestinal System

A B Figure 115-2 A, Z-track method of paracentesis. The skin is pulled approximately 2 cm caudal in relation to the deep abdominal wall by the non–needle-bearing hand while the paracentesis needle is slowly being inserted directly perpendicular to the skin. B, After the peritoneum is penetrated and fl uid return obtained, the skin is released. Note that the needle is angulated caudally. (From Roberts JR: Roberts and Hedges ’ clinical procedures in emergency medicine, ed 6, Philadelphia, 2014, Saunders.)

Procedure for Performing Paracentesis—Continued Steps Rationale Special Considerations 13. After the fl uid is removed, gently Keeps insertion site clean and Inspect catheter to ensure if it intact. remove the catheter and apply pressure dry. Reduces risk for If signifi cant leakage is found, apply to the wound. If the wound is still infection. a stoma bag over the site until leaking fl uid after 5 minutes of direct drainage becomes minimal. pressure, suture the puncture site with a mattress suture (see Procedure 131 ) and apply a pressure dressing. 14. Apply a sterile dressing to the wound Provides a barrier to infection site. and collects fl uid that may leak from wound site. 15. Remove PE and sterile equipment and Standard Precautions. equipment used during the procedure in appropriate receptacles. 16. HH

Expected Outcomes Unexpected Outcomes • Evacuation of peritoneal fl uid for laboratory analysis • Perforation of bowel, bladder, or stomach • Decompression of peritoneal cavity • Lacerations of major vessels (mesenteric, iliac, aorta) • Relief of respiratory compromise • Abdominal wall hematomas • Relief of abdominal discomfort • Laceration of catheter and loss in peritoneal cavity • Incisional • Local or systemic infection • Hypovolemia, hypotension, • Bleeding from insertion site • Ascitic fl uid leak from insertion site • Peritonitis 115 Paracentesis (Perform) 1035

Patient Monitoring and Care Steps Rationale Reportable Conditions These conditions should be reported if they persist despite nursing interventions. 1. Evaluate changes in abdominal Provides evidence of fl uid • Increasing abdominal girth girth. accumulation. 2. Monitor for changes in the Removal of ascitic fl uid should • Respiratory rate >24 breaths per minute respiratory status. relieve pressure on the diaphragm or signifi cant increase from baseline and the resulting respiratory • Increased depth of breathing distress. • Irregular breathing pattern • Pulse oximetry less than 92%, or signifi cant decrease from baseline 3. Monitor for potential Paracentesis interrupts the integrity • Hematuria complications, including bowel of the skin and underlying • Hypotension or bladder perforation, bleeding, peritoneum. • Tachycardia and intravascular volume loss. 4. Monitor vital signs, Rapid changes in intraabdominal • Hypotension temperature, and insertion site pressure may affect heart rate and • Dysrhythmias for drainage or evidence of blood pressure. • Increased temperature infection. Infection is a complication of • Purulent drainage from insertion site paracentesis. • Redness, swelling at insertion site • Abnormal laboratory results (e.g., increased white blood cell [WBC] count) 5. Monitor intake and output. Provides data for evaluation of fl uid • Inappropriate fl uid balance or changes balance status. from baseline fl uid status 6. Monitor abdominal pain and Patients often feel weak and have • Continued pain despite pain level of weakness. abdominal discomfort for a few interventions, if performed hours after the procedure. Follow institutional standard for assessing pain. Identifi es need for pain interventions. 7. Evaluate laboratory data when Provides for evaluation of condition • Red blood cell count >100,000/mm 3 returned. and aids in diagnosis. • Amylase value greater than 2.5 times normal • Alkaline phosphatase value > 5.5 mg/dL • WBC count > 100/mm3 • Positive culture results10,13

Documentation Documentation should include the following: • Patient and family education • Specimens sent for laboratory analysis • Date and time of procedure • Postprocedure vital signs, respiratory status • Description of procedure step by step • Postprocedure comfort/pain level • Patient tolerance of procedure • Abdominal girth • Assessment of insertion site after procedure • Unexpected outcomes • Amount and characteristics of fl uid removed • Nursing interventions

References and Additional Readings For a complete list of references and additional readings for this procedure, scan this QR code with any freely available smartphone code reader app, or visit http://booksite.elsevier.com/9780323376624 .