Abdominal Paracentesis
Eileen D. Brewer
Abdominal paracentesis is a useful procedure to obtain diagnostic information for evaluation of ascites, peritonitis, and intraperitoneal hemorrhage or to initiate therapeutic interventions, such as decompression of ascites for relief of respiratory compromise or the instillation of fluid to promote internal cooling during heat stroke. Diagnostic peritoneal lavage once was the procedure of choice for the early detection of intraabdominal trauma in children, but it has been supplanted by careful serial clinical and laboratory observation and computed tomography (CT) in centers where abdominal CT is readily available. Diagnostic peritoneal lavage still is indicated for the unconscious or intoxicated patient in whom physical observation may be unreliable, in the child who has multiple organ trauma and needs emergent surgery for intracranial or skeletal injuries, or in the presence of a penetrating abdominal wound and uncertainty about bowel integrity or perforation. No
absolute contraindications to abdominal paracentesis exist, but relative contraindications necessitate prudent judgment before undertaking the procedure. Relative contraindications include previous abdominal surgery, pregnancy, bleeding disorders, disruption of the abdominal wall, and marked distention of the bowel, which predisposes to puncture and leakage of bowel contents into the peritoneum.
absolute contraindications to abdominal paracentesis exist, but relative contraindications necessitate prudent judgment before undertaking the procedure. Relative contraindications include previous abdominal surgery, pregnancy, bleeding disorders, disruption of the abdominal wall, and marked distention of the bowel, which predisposes to puncture and leakage of bowel contents into the peritoneum.
TECHNIQUE
The technique for abdominal paracentesis is as follows:
To avoid puncture of organs, be sure the stomach is decompressed and the bladder is empty before starting. Use a nasogastric or orogastric tube, if needed, to decompress the stomach. Have the patient empty the bladder spontaneously or use in-and-out straight catheterization. In the young child, a full bladder is positioned more in the lower abdomen than pelvis and is at greater risk for puncture.
Place the patient in the supine position with the head elevated at least 30 degrees to assure the ascites is dependent in the lower abdomen. Verify the presence of ascites by physical examination.
Choose a puncture site on the abdominal wall. The most commonly used entry site is infraumbilical, in the midline below the umbilicus, approximately one-third of the distance from the umbilicus to the symphysis pubis (Fig. 448.1, site P). A midline supraumbilical approach rarely is used in pediatrics, but is recommended for the patient who is pregnant or has a pelvic fracture (Fig. 448.1, site S). The midline location allows the needle to pass through the relatively avascular linea alba and avoids bleeding complications. If an abdominal scar, local skin infection, or abdominal wall hematoma is present in the midline, an alternative puncture site is the right or left lower quadrant of the abdomen, halfway between the umbilicus and iliac crest, in line with the nipples; the lateral edge of the rectus sheath must be avoided to minimize bleeding complications (Fig. 448.1, sites N). The lower quadrant approach also may be used for young children and neonates, to reduce the possibility of accidental bladder puncture in the midline. Avoid choosing a puncture site near a scar from a previous abdominal surgery, where the bowel may be adherent to the abdominal wall and easily punctured. If concerns arise about the location of viscera, presence of adhesions, or the location of a specific loculated fluid collection to be sampled, use ultrasound guidance for needle insertion.Related posts:
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