When I was a resident, it was impossible to find paracentesis kits in our department. What we did have was a lot of cirrhotic patients who would come by twice a month for a sandwich and a tap (and often a little methadone). Vacuum bottles were never available, so it wasn’t uncommon for us to drain liters of ascites into plastic urinals or bedpans. There was nowhere else to put all that fluid.
Explore This IssueACEP News: Vol 31 – No 11 – November 2012
In our crowded department more than one resident had the sad experience of stepping directly into a tub of warm, hepatitis C-positive ascites, completely saturating their shoes and socks. After pouring a bottle of hydrogen peroxide over each polluted clog, the rest of the shift would be spent working in a makeshift “barrier device,” hospital socks covered with plastic lab bags tied around our feet (crammed back into our moist, foaming shoes). It was a terrible system.
If you have a dedicated paracentesis kit and you need to do a therapeutic (large volume) tap, then use the kit. If you don’t, you can put together a good system using a standard Foley catheter kit, IV tubing, a spinal needle, and some suture removal scissors.
The Basics: There are many steps – I’m just focusing on creating a collection system, so be sure to peruse your favorite procedure text before getting started (especially if it’s been a while).Always make sure your patient has emptied his or her bladder, made their phone call, and isn’t near a meal tray left tantalizingly out of reach. Otherwise you will return to find your patient walking down the hall with their paracentesis tubing skittering across the floor, spewing an amber geyser of ascites onto the linoleum just after it’s been waxed for the fifth time that day.
Informed consent, a coagulation profile and platelet count, ultrasound guidance, local anesthesia, and a sterile prep of the puncture site are non-negotiable steps. I prefer to have the patient upright, and often a chair works better than a sloping stretcher. Different sources recommend a variety of locations for the tap site, though lately I have become a fan of the linea alba, 2 or 3 centimeters below the umbilicus: there are relatively few vessels to lacerate in this area, and needles or catheters protruding from the lower quadrants always seem to get bumped by the patient’s incredibly tight underwear (that they refuse to remove), piles of blankets, phones, meal trays, or visitors.