Paracentesis

Paracentesis

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This high quality video demonstrates paracentesis on a live patient. One of the most commonly performed hospital based procedures, therapeutic paracentesis using a Caldwell needle is shown step by step.  Clinical pearls and common pitfalls associated with paracentesis are discussed in detail.  The video is not downloadable but may be accessed indefinitely by internet from any computer, smart phone, or tablet. Click below to preview the Paracentesis video.

 

The anterior abdominal wall is being prepped with Chlorohexidine swabs, either two 3.5 milliliter swabs or a 10 milliliter swab and allowed to dry for 60 seconds. The area is now being draped with sterile blue towels.

The patient is in the left lateral decubitus position for a left lower quadrant paracentesis or in the semi-upright position for an infra-umbilical paracentesis. 1% lidocaine is used for local anesthesia of the skin using either a 25 or 27 gauge needle to create a skin wheel. This will then be changed to a longer 22 gauge needle for anesthesia of the deeper soft tissues. 

As the needle is introduced, constant negative aspiration is applied to guarantee that you are not in a blood vessel prior to injection of the lidocaine. It is essential to get good anesthesia of the skin and the peritoneum which are the two structures that have the highest density of pain fibers.

An 18 gauge needle is then used to open the puncture site more to allow introduction of the Caldwell needle which is shown here with an inner needle over which you have a blunt catheter. A Z-tract method is utilized to introduce the Caldwell needle with return of amber colored ascitic fluid. At this point the catheter is advanced over the needle and then the needle is withdrawn to have return of ascitic fluid.

A 60 milliliter syringe is then connected to the catheter and amber-colored ascitic fluid is now being aspirated. This ascitic fluid within the 60 milliliter syringe can be introduced directly into culture bottles at the bedside, and then the remainder of the fluid can be submitted to the laboratory for routine diagnostic studies.

The syringe is now being disconnected from the catheter. And now suction tubing will be connected to the catheter on one end, and then the other end will be introduced into an evacuated container where the vacuum will be used for a therapeutic paracentesis. 

Here the ascitic fluid is being directly inoculated into aerobic and anaerobic culture bottles which optimizes the yield of ascitic fluid cultures. The remainder of the ascitic fluid can be sterilely capped and sent to the lab for diagnostic studies.

The Caldwell needle is now being removed, and pressure can be applied to the site, which is subsequently cleaned and a sterile Band-Aid can be applied to complete the paracentesis procedure.