Abdominal

paracentesis

New onset ascites Ascites of unknown origin Suspecting infection Symptomatic treatment of large ascites

Indications

Uncooperative patient Uncorrected bleeding diathesis Acute abdomen that requires surgery Intra-abdominal adhesions Distended bowel Distended urinary bladder Abdominal wall cellulitis at the site of

puncture Pregnancy

Contraindications

Equipment

Commercial paracentesis kits are pre-assembled.

If not available, you will need: 16 G catheter 10 cc syringe Lidocaine 1% One-liter vacuum bottle Thoracentesis kit tubing

Sterile drapes Sterile gloves Antiseptic Sterile gauze Plaster Specimen

container

Identify your patient, introduce yourself Explain the procedure to the patient and

obtain a written informed consent, if possible.

Explain the indication, risks, benefits and alternatives.

Prepare the appropriate equipment Ask the patient to urinate before the

procedure to empty the bladder.

Before the procedure

Position the patient in the bed with the head

elevated at 45-60 degrees, tilt the patient toward the site of paracentesis (allow fluid to accumulate in lower abdomen and air-filled loops of bowel tend to float to the other site, this will minimize trauma to bowel).

Ultrasound scan To identify the presence of encysted ascites To avoid distended bladder, small bowel

adhesions, large veins. How deep to insert the needle

The two recommended areas of abdominal wall entry for paracentesis are as follows:1. 2 cm below the

umbilicus in the midline

2. 5 cm superior and medial to the anterior superior iliac spines on either side

Technique

Explain what is going on while performing the procedure, this will alleviate the patient's anxiety.

Wear sterile gloves Clean the area with

antiseptic solution in a circular fashion from the center out.

Apply the sterile

drapes. You will place the opened parts of the kit on the drape.

Open the 16 G Angiocath and syringe place them on the sterile drapes. Place the 1-L vacuum bottles nearby.

Administer lidocaine at the insertion site

Use scalpel blade to make a

small nick in the skin to allow an easier catheter passage

Insert the needle in Z-technique 

Insert the needle directly perpendicular to the selected skin entry point. Slow insertion in increments of 5 mm is preferred to minimize the risk of inadvertent vascular entry or puncture of the small bowel.

Continuously apply negative pressure to the syringe as the needle is advanced. Upon entry to the peritoneal cavity, loss of resistance is felt and ascitic fluid can be seen filling the syringe .

At this point, advance the device 2-5 mm into the peritoneal cavity to prevent misplacement during catheter advancement.

In general, avoid advancing the needle deeper than the safety mark that is present on most commercially available catheters or deeper than 1 cm beyond the depth at which ascitic fluid was noticed.

Use one hand to firmly

anchor the needle and syringe securely in place to prevent the needle from entering further into the peritoneal cavity

Use the other hand to hold the stopcock and catheter and advance the catheter over the needle and into the peritoneal cavity all the way to the skin

The self-sealing valve

prevents fluid leak. Attach the 60-mL syringe

to the 3-way stopcock and aspirate to obtain ascitic fluid and distribute it to the specimen vials and send it to the lab for analysis

Connect one end of the fluid collection tubing to the stopcock and the other end to a vacuum bottle or a drainage bag

If the flow stops, kink or clasp the tubing to avert loss of suction, then break the seal and manipulate the catheter slightly, then reconnect and see if flow resumes.

Post procedure

Remove the catheter after the desired amount of ascitic fluid has been drained.

Apply firm pressure Place sterile gauze a bandage

over the skin puncture site. Ask the patient to lie for 4 hours

and the nurse to check vital signs every hour for 4 hours to avoid hypotension.

Give 25 cc of albumin (25% solution) for every 2 liters of ascitic fluid removed.

Write a procedure note which documents the

following: Patient consent Indications for the procedure Relevant labs, e.g. INR/PTT, platelet count Procedure technique, sterile prep, anesthetic,

amount of fluid obtained, character of fluid, estimated blood loss.

Any complications Lab tests requested. Color, pH, Protein, albumin,

specific gravity, glucose, bilirubin, amylase, lipase, triglyceride, LDH, Cell count total and differential, Culture &Sensitivity, Gram stain, AFB, Cytology

Persistent leak from the puncture site Abdominal wall hematoma Perforation of bowel Introduction of infection Hypotension after a large-volume paracentesis Dilutional hyponatremia Catheter fragment left in the abdominal wall or

cavity

Complications

Thoracosente

sis

Symptomatic treatment of large pleural

effusions Treatment of empyema diagnosis of underlying cause of pleural

effusions

Indication

There are no absolute contraindications for

thoracentesis. Relative contraindications include the

following: Uncorrected bleeding diathesis Chest wall cellulitis at the site of puncture

Contraindications

Equipment

Thoracosentesis set If not available assemble

the followings: Syringe - 10 mL Syringe - 5 mL Syringe - 60 mL Tubing set with

aspiration/discharge device

Antiseptic solution Lidocaine 1% solution,

Specimen cap for 60-mL syringe

Specimen vials or blood tubes

Drainage bag or vacuum bottle

Sterile drapes Sterile towels Scalpel Adhesive plaster Sterile gauze Surgical gloves

Identify your patient, introduce yourself Explain the procedure to the patient and

obtain a written informed consent. Explain the indication, risks, benefits and

alternatives. Prepare the appropriate equipment Give the patient anxiolytics (IV midazolam

or lorazepam) to attenuate the anxiety.

Before the procedure

Place the patient in a

seated position, leaning slightly forward and resting the head on the arms or hands or on a pillow, which is placed on an adjustable bedside table.

This position facilitates access to the posterior axillary space, which is the most dependent part of the thorax.

Technique

Explain what is going on while performing the procedure

After positioning ultrasonography is performed to confirm the pleural effusion, assess its size, look for loculations, determine the optimal puncture site and minimize complications

The optimal puncture site may be determined by searching for the largest pocket of fluid superficial to the lung

Wash with antiseptic solution Placed sterile drape over the

puncture site The skin, subcutaneous tissue,

rib periosteum, intercostal muscles, and parietal pleura should be well infiltrated with anesthetic lidocaine

Use scalpel blade to make a small nick in the skin to allow an easier catheter passage

The device is advanced over

the superior aspect of the rib while applying negative pressure until pleural fluid is obtained

The neurovascular bundle is located at the inferior border of the rib and should be avoided.

At 5 cm depth (mark on the device), the hemithorax is usually entered, and the needle don't need be advanced any further.

Advance the

catheter over the needle and into the pleural cavity all the way to the skin (if possible).

Connect the catheter

to syringe or vacuum bottle, the pleural effusion is drained until the desired volume has been removed for symptomatic relief or diagnostic analysis

Post procedure

Remove the catheter after the desired amount of pleural fluid has been drained.

Apply firm pressure and place sterile gauze and bandage over the skin puncture site

Position the patient on the unaffected side for 1 hour. This allows the pleural puncture to heal

Give analgesia Frequently check vital signs, oxygen saturation and

breath sounds to detect complications Send sample for analysis Write procedure note Request CXR to check for pneumothorax

Complications

Major complications include the following: Pneumothorax Hemothorax Laceration of the

liver or spleen Diaphragmatic

injury Empyema Tumor seeding

Minor complications include the following: Pain Dry tap Cough Subcutaneous

hematoma Subcutaneous

seroma Vasovagal syncope

Chest aspiration for

tension pneumothorax

Tension

pneumothorax A tension

pneumothorax is a life-threatening condition that develops when air is trapped in the pleural cavity under positive pressure, displacing mediastinal structures and compromising cardiopulmonary function

60 ml disposable syringe 3-way stopcock Cannula size 16 Antiseptic Sterile gloves

Equipment

Explain the procedure to the patient (in

short terms) and obtain permission Prepare your equipment Position the patient in the supine

position.

Before the procedure

Wash with antiseptic (if possible) The aspiration carried out in the second inter-costal

space in the mid-clavicular line just above the third rib (air accumulate in the upper chest unlike fluid).

Give local anesthesia with lignocaine. (if possible) Insert 16 G intravenous (IV) cannula On entry into the pleural cavity, a slight "pop" is often

felt and a gush of air will come out (hold the cannula tight)

Withdraw the needle and 3 way valve stopcock is inserted

A 50 cc syringe connected to the cannula Aspirate and expel the air with the needle

Technique

Note the amount of air aspirated. Aspirate until you feel resistance or if the patient

began to cough excessively Withdraw the cannula and seal the entry site Watch closely for signs of re-accumulation. If

this should occur and give rise to significant distress, a chest drain should be inserted and connected to an underwater seal.

Repeated aspiration will buy time until chest tube is inserted

Request CXR to assess efficiency of aspiration