Indications for a paracentesis


Diagnostic Paracentesis

– Evaluate etiology of new- onset ascites
– Rule out spontaneous bacterial peritonitis
– Follow-up of therapy for spontaneous bacterial peritonitis

Therapeutic Paracentesis

– Respiratory compromise in patients with massive ascites
– Management of refractory, cirrhotic ascites
– Adjunctive management of hepatorenal syndrome

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Contraindications for a paracentesis


Absolute contraindications

– Acute abdomen requiring exploratory surgery
– Infected abdominal wall at the entry site
– Uncooperative patient
– DIC or significant fibrinolysis

Relative contraindications

– Severe bowel distension or bowel obstruction
– Multiple prior abdominal surgeries
– Pregnancy
– INR > 5 (INR > 2.5 on warfarin)
– Coagulopathy with PTT 1.5x upper limit of normal
– Incidence of severe hemorrhage 0.2%(N= 4,500 paracenteses)
– Bleeding is reduced with ultrasound- guidance
– Thrombocytopenia (Platelets<25k)
– Use of DOAC or fondaparinux

Complications of a paracentesis

Paracentesis Complications

Major Complications

– Bowel or bladder perforation
– Hemoperitoneum (0.2%)
– Hypotension with large volume paracentesis
– Hepatorenal syndrome

Minor Complications

– Persistent ascitic fluid leak (1 % risk)
-Stitch vs ostomy bag vs dermabond 1 mL injected 1 cm deep
– Metastatic seeding of needle tract (rare)
– Soft tissue infection at puncture site
– Abdominal wall hematoma

Equipment for a paracentesis

Paracentesis Equipment

  • Chlorhexidine swabs
  • 10 mL syringe
  • 18 gauge needle
  • 27 gauge needle
  • 1% lidocaine
  • 60 mL syringe
  • Blood collection tubing
  • Sterile towels
  • Evacuated container

Angiocatheter should be at least 3 – 3.5 inches for obese patients
– Can also use a 3 ¼ inch Caldwell needle or a DPL needle for the procedure
Kits: Safe-T-Centesis Tray (Carefusion) or Abdominal Paracentesis Kit (Teleflex)

Proper positioning and technique for a paracentesis

Paracentesis Entry Sites

Midline Approach

  • 2 cm below umbilicus
  • Semi- recumbent and flat

LLQ Approach

  • 3-4 cm towards umbilicus from anterior superior iliac spine
  • Semi-recumbent position with left lateral tilt

Ultrasound-directed paracentesis

Ascitic fluid analysis

Serum- to- Ascites Albumin Gradient (SAAG)

SAAG ≥ 1.1 gm/ dL indicates that the patient has
portal hypertension (97% accuracy)

SAAG < 1.1 indicates that the patient has a cause of
ascites other than portal hypertension

Coding for a paracentesis

Coding for Paracentesis

  • 49082 Abdominal paracentesis without image guidance
  • 49083 Abdominal paracentesis with image guidance

– 52 Procedures that are incomplete or discontinued at physician’s discretion

– 53  Procedures that are discontinued because the patient’s life is endangered