Fluid Management
Procedure Guide
Indications
New-onset or worsening ascites
Can be diagnostic or therapeutic
Contraindications
Unsafe window for percutaneous access
Uncorrected coagulopathy (INR >2.0)
Pre-procedure Care
Review imaging if available or use US to assess volume, adjacent organs, and vasculature (e.g. inferior epigastric).
Can continue antiplatelet and anticoagulation.
Procedure
Pre-scan and mark spot (ideally R or L paracolic gutters)
Anesthetize the skin, subcutaneous tissues, and peritoneum.
Advance catheter into the peritoneal cavity under ultrasound guidance (lots of variation)
Classic is a Yueh needle with straight or pigtail catheter to advance over the needle.
Some kits come with an atraumatic “centesis” needle with catheter for access.
Others will use a Yueh or 19G coaxial needle, advance a working wire, and place a 5 Fr pigtail or 7-8 Fr pigtail drain.
Other directly trocar in a 7-8 Fr pigtail drain to reduce the number of exchanges for patient comfort
Attached tubing to vacuum bottle or wall suction. Can increase output with slight repositioning and massaging the abdomen for the last bit of fluid.
Remove catheter and achieve hemostasis.
If leaking, Dermabond can be helpful to seal it.
Complications
Ascitic fluid leak (5%), bowel perforation/infection (6/1000), bleeding, paracentesis-induced circulatory dysfunction (PICD), hypotension, hyponatremia,
Post-procedure care
If diagnostic, send fluid for appropriate studies, e.g., cytology, protein, LDH, triglycerides, amylase, glucose, CEA.
Calculate SAAG (>1.1 suggests cirrhosis or CHF; <1.1 suggests peritonitis, vasculitis, nephrosis, Meigs’ syndrome)
Ascitic fluid total protein (AFTP) <2.5 g/dl suggests cirrhosis whereas >2.5 g/dl suggests CHF
Post-procedure IV albumin (6-8g per liter removed) if >5L removed, significantly reduces risk of PICD