Abdominal paracentesis

1. Abdominal paracentesis

2. Indications • New onset ascites • Ascites of unknown origin • Suspecting infection • Symptomatic treatment of large ascites

3. Contraindications • Uncooperative patient • Uncorrected bleeding diathesis • Acute abdomen that requires surgery • Intra-abdominal adhesions • Distended bowel • Distended urinary bladder • Abdominal wall cellulitis at the site of puncture • Pregnancy

4. Equipment • Commercial paracentesis kits are pre-assembled. • If not available, you will need: • 16 G catheter • 10 cc syringe • Lidocaine 1% • One-liter vacuum bottle • Thoracentesiskit tubing • Sterile drapes • Sterile gloves • Antiseptic • Sterile gauze • Plaster • Specimen container

6. Before the procedure • Identify your patient, introduce yourself • Explain the procedure to the patient and obtain a written informed consent, if possible. • Explain the indication, risks, benefits and alternatives. • Prepare the appropriate equipment • Ask the patient to urinate before the procedure to empty the bladder.

7. Position the patient in the bed with the head elevated at 45-60 degrees, tilt the patient toward the site of paracentesis (allow fluid to accumulate in lower abdomen and air-filled loops of bowel tend to float to the other site, this will minimize trauma to bowel). • Ultrasound scan • To identify the presence of encysted ascites • To avoid distended bladder, small bowel adhesions, large veins. • How deep to insert the needle

8. The two recommended areas of abdominal wall entry for paracentesis are as follows: • 2 cm below the umbilicus in the midline • 5 cm superior and medial to the anterior superior iliac spines on either side

9. Technique • Explain what is going on while performing the procedure, this will alleviate the patient's anxiety. • Wear sterile gloves • Clean the area with antiseptic solution in a circular fashion from the center out.

10. Apply the sterile drapes. You will place the opened parts of the kit on the drape. • Open the 16 G Angiocath and syringe place them on the sterile drapes. Place the 1-L vacuum bottles nearby. • Administer lidocaine at the insertion site

11. Use scalpel blade to make a small nick in the skin to allow an easier catheter passage • Insert the needle in Z-technique • Insert the needle directly perpendicular to the selected skin entry point. Slow insertion in increments of 5 mm is preferred to minimize the risk of inadvertent vascular entry or puncture of the small bowel.

12. Continuously apply negative pressure to the syringe as the needle is advanced. Upon entry to the peritoneal cavity, loss of resistance is felt and ascitic fluid can be seen filling the syringe . • At this point, advance the device 2-5 mm into the peritoneal cavity to prevent misplacement during catheter advancement. • In general, avoid advancing the needle deeper than the safety mark that is present on most commercially available catheters or deeper than 1 cm beyond the depth at which ascitic fluid was noticed.

13. Use one hand to firmly anchor the needle and syringe securely in place to prevent the needle from entering further into the peritoneal cavity • Use the other hand to hold the stopcock and catheter and advance the catheter over the needle and into the peritoneal cavity all the way to the skin

14. The self-sealing valve prevents fluid leak. • Attach the 60-mL syringe to the 3-way stopcock and aspirate to obtain ascitic fluid and distribute it to the specimen vials and send it to the lab for analysis

15. Connect one end of the fluid collection tubing to the stopcock and the other end to a vacuum bottle or a drainage bag • If the flow stops, kink or clasp the tubing to avert loss of suction, then break the seal and manipulate the catheter slightly, then reconnect and see if flow resumes.

16. Post procedure • Remove the catheter after the desired amount of ascitic fluid has been drained. • Apply firm pressure • Place sterile gauze a bandage over the skin puncture site. • Ask the patient to lie for 4 hours and the nurse to check vital signs every hour for 4 hours to avoid hypotension. • Give 25 cc of albumin (25% solution) for every 2 liters of ascitic fluid removed.

17. Write a procedure note which documents the following: • Patient consent • Indications for the procedure • Relevant labs, e.g. INR/PTT, platelet count • Procedure technique, sterile prep, anesthetic, amount of fluid obtained, character of fluid, estimated blood loss. • Any complications • Lab tests requested. Color, pH, Protein, albumin, specific gravity, glucose, bilirubin, amylase, lipase, triglyceride, LDH, Cell count total and differential, Culture &Sensitivity, Gram stain, AFB, Cytology

18. Complications • Persistent leak from the puncture site • Abdominal wall hematoma • Perforation of bowel • Introduction of infection • Hypotension after a large-volume paracentesis • Dilutionalhyponatremia • Catheter fragment left in the abdominal wall or cavity

19. Thoracosentesis

20. Indication • Symptomatic treatment of large pleural effusions • Treatment of empyema • diagnosis of underlying cause of pleural effusions

21. Contraindications • There are no absolute contraindications for thoracentesis. • Relative contraindications include the following: • Uncorrected bleeding diathesis • Chest wall cellulitis at the site of puncture

22. Equipment • Thoracosentesis set • If not available assemble the followings: • Syringe - 10 mL • Syringe - 5 mL • Syringe - 60 mL • Tubing set with aspiration/discharge device • Antiseptic solution • Lidocaine1% solution, • Specimen cap for 60-mL syringe • Specimen vials or blood tubes • Drainage bag or vacuum bottle • Sterile drapes • Sterile towels • Scalpel • Adhesive plaster • Sterile gauze • Surgical gloves

24. Before the procedure • Identify your patient, introduce yourself • Explain the procedure to the patient and obtain a written informed consent. • Explain the indication, risks, benefits and alternatives. • Prepare the appropriate equipment • Give the patient anxiolytics (IV midazolam or lorazepam) to attenuate the anxiety.

25. Place the patient in a seated position, leaning slightly forward and resting the head on the arms or hands or on a pillow, which is placed on an adjustable bedside table. • This position facilitates access to the posterior axillary space, which is the most dependent part of the thorax.

26. Technique • Explain what is going on while performing the procedure • After positioning ultrasonography is performed to confirm the pleural effusion, assess its size, look for loculations, determine the optimal puncture site and minimize complications • The optimal puncture site may be determined by searching for the largest pocket of fluid superficial to the lung

27. Wash with antiseptic solution • Placed sterile drape over the puncture site • The skin, subcutaneous tissue, rib periosteum, intercostal muscles, and parietal pleura should be well infiltrated with anesthetic lidocaine • Use scalpel blade to make a small nick in the skin to allow an easier catheter passage

28. The device is advanced over the superior aspect of the rib while applying negative pressure until pleural fluid is obtained • The neurovascular bundle is located at the inferior border of the rib and should be avoided. • At 5 cm depth (mark on the device), the hemithorax is usually entered, and the needle don't need be advanced any further.

29. Advance the catheter over the needle and into the pleural cavity all the way to the skin (if possible).

30. Connect the catheter to syringe or vacuum bottle, the pleural effusion is drained until the desired volume has been removed for symptomatic relief or diagnostic analysis

31. Post procedure • Remove the catheter after the desired amount of pleural fluid has been drained. • Apply firm pressure and place sterile gauze and bandage over the skin puncture site • Position the patient on the unaffected side for 1 hour. This allows the pleural puncture to heal • Give analgesia • Frequently check vital signs, oxygen saturation and breath sounds to detect complications • Send sample for analysis • Write procedure note • Request CXR to check for pneumothorax

32. Complications • Major complications include the following: • Pneumothorax • Hemothorax • Laceration of the liver or spleen • Diaphragmatic injury • Empyema • Tumor seeding • Minor complications include the following: • Pain • Dry tap • Cough • Subcutaneous hematoma • Subcutaneous seroma • Vasovagal syncope

33. Chest aspiration for tension pneumothorax

34. Tension pneumothorax • A tension pneumothorax is a life-threatening condition that develops when air is trapped in the pleural cavity under positive pressure, displacing mediastinal structures and compromising cardiopulmonary function

35. Equipment • 60 ml disposable syringe • 3-way stopcock • Cannula size 16 • Antiseptic • Sterile gloves

36. Before the procedure • Explain the procedure to the patient (in short terms) and obtain permission • Prepare your equipment • Position the patient in the supine position.

37. Technique • Wash with antiseptic (if possible) • The aspiration carried out in the second inter-costal space in the mid-clavicular line just above the third rib (air accumulate in the upper chest unlike fluid). • Give local anesthesia with lignocaine. (if possible) • Insert 16 G intravenous (IV) cannula • On entry into the pleural cavity, a slight "pop" is often felt and a gush of air will come out (hold the cannula tight) • Withdraw the needle and 3 way valve stopcock is inserted • A 50 cc syringe connected to the cannula • Aspirate and expel the air with the needle

39. Note the amount of air aspirated. • Aspirate until you feel resistance or if the patient began to cough excessively • Withdraw the cannula and seal the entry site • Watch closely for signs of re-accumulation. If this should occur and give rise to significant distress, a chest drain should be inserted and connected to an underwater seal. • Repeated aspiration will buy time until chest tube is inserted • Request CXR to assess efficiency of aspiration