ASCITIC DRAINAGE: STEPS TO CARRY OUT IN EXAMINE
BRIEF DESCRIPTION:
Indications
•• Diagnostic – investigating a patient with ascites for the cause or when spontaneous bacterial peritonitis is suspected
•• Therapeutic – for symptomatic relief in patient with large ascites
Contraindications
•• Infection at insertion site
•• Surgical abdomen
•• Distended bowel or bowel obstruction
•• Intra-abdominal adhesions
•• Too little fluid to tap – this can be confirmed by USS in ED if available
•• Uncorrected coagulopathy is a relative contraindication; most patients with liver failure have some degree of coagulopathy and thrombocytopaenia. However if the coagulopathy is severe or platelets are lower than 40 × 109/L the procedure will normally be deferred until the abnormality is corrected.
Complications
•• Haematoma at site of procedure
•• Introduction of infection
•• Hypovolaemia leading to shock and renal failure
•• Persistent leakage of ascitic fluid from the drain site
•• Haemoperitonium (uncommon)
•• Bowel perforation (uncommon)
Common sites
•• Right or left iliac fossa
•• Ultrasound guided marking on skin where the collection is closest to the skin
Pre-procedure check
•• Drugs – local anaesthetic-1% lignocaine
•• Cleaning and preparation – skin cleaning with chlorhexidine or iodine
•• Equipment:
–– Minor dressing pack, with sterile drapes
–– 10 mL syringe and an orange and a green needle
–– 20 mL syringe
–– Bonanno pigtail catheter or other purpose-built paracentesis catheter or drip-set
–– Drainage bag
–– Dressing and suture to secure the catheter in place
–– Bottles to take samples
• Monitoring – intravenous line connected and running.
• Sterility – sterile gloves and field
Technique
Ensure all the equipment is available and easily accessible. The patient should be lying supine, preferably leaning towards the side where you plan to tap and should have an empty bladder. Percuss the abdomen and confirm dullness to percussion at the chosen site. Hands should be washed and dried before wearing sterile gloves. Clean the selected area with povidone-iodine or chlorhexidine skin solution.
Establish sterility and cover the area of the abdomen with a sterile drape leaving a window for the drain insertion.
The site for the procedure is approximately 15 cm lateral and 2–3 cm below the umbilicus. At this point the rectus and anterior abdominal wall muscles become aponeurotic. This site is also located away from the epigastric arteries. Consider using ultrasound to locate the best site.
Infiltrate an appropriate local anaesthetic at the site, first using an orange 25G needle in the skin and then using a larger 21G green needle in the abdominal wall. On advancing the needle into the peritoneal cavity one can feel a give and aspirate peritoneal fluid.
Attach a 20 mL syringe to the end of the Bonanno catheter. Insert using the so-called Z technique. Pull the skin taught and insert the needle perpendicular to the skin. Release the
skin and advance the needle obliquely in the subcutaneous tissue before advancing the needle perpendicular to the abdominal wall in the peritoneal cavity. This ensures that the holes in the skin and the abdominal wall are away from each other and therefore there is less chance of leakage of the fluid after drain removal.
Once in the peritoneal cavity, aspirate the syringe to confirm placement in the ascitic fluid. Once aspirating freely, advance the needle a few millimetres and then advance the catheter further and withdraw the needle from the catheter. If the fluid cannot be aspirated from the catheter when the needle has been withdrawn, do not re-advance the needle in the catheter. This is because the catheter is has a ‘pig-tail’ end which tends to curl up. If the
needle is advanced, it may cut through, rather than advance into the catheter.
If necessary take samples for cytology, culture, neutrophil count and albumin as required and connect the catheter to the drainage bag. Secure the catheter in place using a
suture.
Clear the sharps and other equipment appropriately. The amount of fluid to be removed and duration for which the catheter is to be left in place will depend on the situation. If the catheter is for therapeutic drainage, it is recommended for it not to remain inserted overnight.
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