1. Evaluation of the etiology of ascites
2. Detection of perforated viscus in a patient with an acute- abdomen or following blunt trauma to the abdomen.
3. Therapy for massive ascites. (e.g. unresponsive to diuretics or interfering with respiration)

1. Disorder of blood coagulation*:
1. Prothrombin time>5 sec of control
2. platelet count <50m000/mm3
2. Intestinal obstruction
3. Pregnancy for fear of puncturing the uterus
4. know pneumoperitoneum (paracentesis is generally unnecessary since the patient is likely to be considered for surgery for ruptured viscus)
5. Infection of the abdominal wall
6. relative contraindication:
1. poor patient cooperation
2. history of multiple abdominal surgeries

*consider using FP or platelet transfusion if severe coagulopathy exist.

1. Obtain hematocrit, prothrombin time, and platelet count at least 48hr prior to procedure.
2. Explain the risks, benefits, and details of the procedure to the patient.
3. Obtain informed written consent- major risks are very unusual- infection, needle injury to bowel, bladder, etc. Abdominal wall hematoma. Large volume paracentesis may cause hypotension.

1. Sterile gloves.
2. providone-iodine and alcohol;sterile gauze
3. draping towels
4. local anesthetic (licaine 1%) and needles
5. Syringes: 10cc x 2, 50cc x 2
6. paracentesis needles:
1. 16, 18, 20 gauge
2. spinal needle (18, 20 gauge) for obese patients
7. Sterile specimen tubes.
8. If infection suspected, blood culture bottles for bedside innoculation

1. Have patient empty bladder
2. Position the patient in the bed with the head elevated 45 -90 degrees. This allows fluid to accumulate in lower abdomen. (If there is a small volume of ascetic fluid, the patient can be asked to assume the knee-hand position on the side of the bed with the physician working from below.)
3. Identify the point of aspiration: in the midline midway between the umbilicus and pubic bone. If scars from previous surgeries are present, choose the right or left lower quadrant lateral to the rectus muscles.
4. Put on sterile gloves.
5. Sterilize the site with providone-iodine and then alcohol.
6. Place sterile draping towels
7. Inject lidocaine don to and including the peritoneum
8. Insert 18-20 gauge needle on 10cc syringe slowly into the abdominal cavity at a slightly oblique angle to the skin after pulling the skin down slightly (the "Z track technique"- may reduce the risk of ascites leaks), aspirate intermittently.
9. Gently aspirate 10cc fluid, and then attach 50cc syringe and aspirate further quantities of fluid as needed for predetermined analysis (usually 20-200cc)
10. If no fluid returns after several attempts, ultrasound-directed aspiration should be used.
11. Remove the needle and place an adhesive bandage or pressure dressing over the site.

3. Detach the needles from the syringe once you are comfortable with a steady flow of fluid. Attach the tubing and stopcock if you are doing a therapeutic or large volume tap.
4. If you have all you need, close the stopcock and remove the needle.
5. Apply pressure and then a dressing to the site.
6. If there is leaking of ascites after you remove the catheter, a stitch or two at the incision may seal it; usually self-healing even if you do not stitch.
7. Monitor vital closely after large volume tap. Consider resuscitation fluids/colloids if needed.

The analysis of the aspirated fluid will be determined by the individual patient and his or her diagnosis. Routine test employed include the following:

1. Total protein and albumin
2. Red and white blood cell count (purple top tube)
3. Gram and acid-fast bacillus stain
4. amylase, albumin, serum albumin
5. culture (bacterial, AFB, fungal, viral) (use aerobic and anaerobic bottles)
6. cytology (preferably full 500cc bottle sent)
7. other chemistries as indicated (LDH< Tg, chol, CEA etc.)

References

1. Kellerman PS, Linas SL (1990):Large-volume paracentesis in the treatment of ascites. Ann Intern Med 112:889-890
2. Runyon BA, UMland ET, Merlin T (1987): Inoculation of blood culture bottles with ascitic fluid. Improve detection of spontaneous bacterial pertonitis. Arch Intern Med 147:73-75
3. Slaerno F, Badalamenti S, Incerti P, et al (1987): Repeated paracentesis and i.v. albumin infusion to treat "tense" ascites in cirrhotic patients. " J Hepatol 5:102-8
4. Rector, Reynolds, (1984): Superiority of serum-ascites albumin difference over ascites total protein concentration in separation of "transudative" and "exudative" ascites. Am J Med 77:83-5.
5. Runyon BA (1986): Paracentesis of ascitic fluid. A safe procedure. Arch Intern Med 146:2259-2261
6. Mallory A, Schaefer JW (1978): Complication of diagnostic paracentesis in patients with liver disease. JAMA 239;628-30