Expose the patient's abdomen fully and percuss out ascitic fluid. Demonstrate shifting dullness and a fluid thrill. Percuss either right or left iliac fossa – this is where you will insert the drain. Mark it with a pen if necessary.
Prepare yourself and your cart as follows:
– wash your hands
– open up your dressing pack
– pour iodine into a bowl
– put on sterile gloves.
Draw up the lidocaine using the green needle. Replace the green needle with the orange needle and fill this, too.
Have your helper open the ascitic drain and bag for you. The ascitic drain is usually a small-bore tube with an introducer inside. It is inserted like an IV cannula. Familiarize yourself with it before proceeding.
Prepare the skin and inject local anesthetic with the orange and then the green needle. You will finally feel a give; then aspirate the straw-colored ascitic fluid easily. Withdraw the needle slightly and inject more local anesthetic.
Remove the needle and nick the skin over the local anesthetic with a scalpel.
Take the ascitic drain, with a 20- or 50-ml syringe attached, and enter the skin at a 90° angle, pushing gently until ascitic fluid is again aspirated. Now, as with a cannula, slowly withdraw the introducer while at the same time advancing the drain until it is inserted (Fig. 13).
No aspiration: you are in the wrong place. Repercuss and try again. If you are still unsuccessful, then you might need an ultrasound to mark a spot for you.
No drainage: think of the following:
blockage – try flushing drain with sterile saline
kink in the tube – check where tube is tied in and ensure it is not kinked
drain has fallen out – remove the drain and, if necessary, replace with new drain at new site.
Fig. 13 Ascitic tap.
Remove the introducer completely and attach it to the drainage bag. Clamp it when 1 L has been drained. Large-volume paracentesis can be carried out as a therapeutic measure if accompanied by IV volume replacement (e.g., with 1 unit of 20% albumin for each 2 L drained). Check with your chief resident.
Suture the drain in place and cover it with an adhesive dressing. Using saline, clean the patient of remaining iodine.
Diagnostic aspirations should be performed with the same care as insertion of a drain. Diagnostic aspirations are simple in that they can be performed with a green needle. Enough fluid should be taken for culture (microscopy, and culture and sensitivity), protein, glucose, and alpha fetoprotein (ΑFP).
