Collection System: Take a standard Foley kit and clamp off the hose near to the collection bag, and then cut a hole in the collection tubing using sterile scissors (disposable ones from a suture removal kit are fine). Next, cut some IV tubing with the same sterile scissors and tuck one end into the hole in the Foley collection tubing. Then hang the Foley bag below the patient or even place it on the floor. Connect other end of the IV tubing (with the screw hub) to your puncture needle. The IV tubing should be long enough to prevent small movements from yanking it out of the patient or the Foley tubing, but shouldn’t have excessive slack. Three feet (~90 cm) is a good place to start. A three-way stopcock is a nice addition, but not essential. (Figure 1).

Needle or Angiocatheter? Since we’re talking about a “no kit” situation with an anticipated high volume paracentesis, you’re left with the option of using an angiocathether (from an IV or central line kit) or a simple needle to puncture the peritoneal cavity. Both can work, but where I work most IV angiocatheters tend to be too short and kink or collapse too easily. I usually use a 20-gauge spinal needle with the plastic needle guard cut short to match the abdominal wall thickness from your preliminary ultrasound. By leaving the needle guard on, the patient can’t ram the needle through the bowel and into the aorta and spinal cord should he or she decide to do push-ups.

Insert the spinal needle using sterile technique after anesthetizing the patient. Put some caudal tension on the skin before inserting your needle to help the tract seal up once you remove the needle. If you leave the stylet in the needle, remove it frequently as you advance a few millimeters at a time. Once you get flow of ascites, connect your IV tubing.

You’ll need to support the needle with a few gauze rolls taped to the patient’s abdomen. (Figure 2). Some people like to add a three-way stopcock to the mix.

What Next?: Once ascites starts collecting in the Foley bag, all you have to do is watch. This system is sterile, and it allows you to precisely measure the volume of fluid you are removing – my personal cutoff is 2.5 liters, though some people will remove much more. If you need specimens for the lab, use the drainage port in the Foley bag to collect sterile samples. Once fluid stops draining, resist the temptation to wobble the needle around in the patient’s abdomen in the hopes of getting a little more. Remove the needle carefully to avoid getting stuck.