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Practical Procedures
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Ascitic tap and/or drainage (paracentesis)


Equipment
Method
Pitfalls
Simple aspiration

 
 
  Equipment
 
  • Dressing pack
  • Abundant supply of gauze pads
  • Sterile gloves
  • Iodine/cleaning solution
  • 10-ml syringe
  • 50-ml syringe
  • 21-gauge (green) needles
  • 27-gauge (orange) needles
  • 1% or 2% lidocaine
  • Ascitic drain and bag
  • Scalpel
  • Adhesive dressing

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  Method
   
 
  • Explain to the patient what you are going to do.
  • 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).

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  Pitfalls
   
 

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.

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  Simple aspiration
   
 

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).

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