Paracentesis Complications

Major bleedingScreen Shot 2015-05-12 at 7.26.03 PM

  • Hematoma and hemoperiteneum requiring transfusion occurs after 1% of paracentesis5
  • Select a safe location for needle entry by avoiding
    • Rectus abdominus muscles contain large epigastric arteries
    • Surgical scars which often have neovascularization
    • Engorged subcutaneous veins
    • Abdominal wall bruises and hematomas
  • Use the linear (vascular) probe to assess for subcutaneous vessels prior to needle puncture
    • 1 institution found vessels in the path of their needle 10% of the time, and reduced major bleeding with routine use of the linear US probe7

para linear probe vessel

  • See previous page for transfusion indications

Acute kidney injury, hypotension and hyponatremia

  • Large volume paracentesis should be avoided in AKI and hemodynamically unstable patients1
    • Post paracentesis there is large fluid shift back into the peritoneum, reducing the effective arterial circulation
  • Prevention with albumin
    • A meta-analysis demonstrated that albumin significantly reduced post-paracentesis mortality from 14% -> 12%1
    • If ≥ 5 liters are removed, 6 gram of albumin should be given for every liter removed 1-4
      • 1 bottle of 25% albumin has 25gm in 100ml
      • For example, if 8L are removed, give 48 grams of albumin which is about 200ml of 25% albumin
    • Albumin should be given during the procedure or immediately after
    • Consider albumin in all cirrhotics with baseline hypotension

Bowel perforation

  • Occurs in less than 0.5%5
  • Prevention
    • Avoid surgical scars where adhesions may form
    • Use ultrasound to find the deepest fluid pocket of at least 3cm
  • Most perforations cause self-limited peritonitis that does not require surgical intervention

Persistent ascites fluid leakage

  • Occurs in up to 5% of patients5
  • Prevention
    • Offsetting the skin puncture and the peritoneal puncture should decrease the risk of leakage, but it has never been studied 6
    • 2 techniques4
      • Z track
        • pull the skin 2cm with your non-dominate hand during needle entry
      • Angled insertion technique
        • Insert the needle at a 45°
        • Be sure your fluid pocket seen on US can accommodate this needle trajectory
  • Treatment
    • Control and monitor fluid output with an ostomy bag
    • If persistent, and you can place a suture to close the skin

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References

  1. Bernardi, M., Caraceni, P., Navickis, R.J. & Wilkes, M.M. Albumin infusion in patients undergoing large-volume paracentesis: a meta-analysis of randomized trials. Hepatology 55, 1172-81 (2012).
  2. Gines, P., Cardenas, A., Arroyo, V. & Rodes, J. Management of cirrhosis and ascites. N Engl J Med 350, 1646-54 (2004).
  3. Runyon, B.A. Management of adult patients with ascites due to cirrhosis: an update. Hepatology 49, 2087-107 (2009).
  4. Thomsen, T.W., Shaffer, R.W., White, B. & Setnik, G.S. Videos in clinical medicine. Paracentesis. N Engl J Med 355, e21 (2006).
  5. De Gottardi, A. et al. Risk of complications after abdominal paracentesis in cirrhotic patients: a prospective study. Clin Gastroenterol Hepatol 7, 906-9 (2009).
  6. Wong, C.L., Holroyd-Leduc, J., Thorpe, K.E. & Straus, S.E. Does this patient have bacterial peritonitis or portal hypertension? How do I perform a paracentesis and analyze the results? JAMA 299, 1166-78 (2008).
  7. Barsuk, Jeffrey H., et al. “Vascular Ultrasonography: A Novel Method to Reduce Paracentesis Related Major Bleeding.” Journal of hospital medicine (2017): E1-E3.