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I. INDICATIONS

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  1. To obtain peritoneal fluid for diagnostic tests to determine the cause of ascites. Ascites is an excessive amount of fluid in the peritoneal cavity and in the neonate it is usually urinary, biliary, or chylous. Other causes can occur but are less common.

    1. Urinary ascites. Due to perforation of the ureter, intrarenal collecting system, or bladder (intraperitoneal) often caused by a distal obstruction. The most common cause is posterior urethral valves. Other causes: ureterocele, ureteral stenosis, urethral stenosis/atresia, neurogenic bladder, urogenital sinus, congenital nephrotic syndrome, bladder neck obstruction, and renal vein thrombosis.

    2. Biliary ascites. Due to perforation of bile duct (more common), injury to the bile ducts, or a choledochal cyst.

    3. Chylous ascites. Slightly more common in males and usually idiopathic. Other causes include a congenital lymphatic abnormality (more common), or disruption of the lymphatic ducts from trauma or surgery.

    4. Hepatocellular ascites. Can be caused by neonatal hepatitis, viral hepatitis, congenital hepatic fibrosis, Budd-Chiari syndrome, or hepatic/portal vein thrombosis.

    5. Pancreatic ascites. Usually caused by trauma or pseudocysts.

    6. Gastrointestinal causes of ascites. Any perforation of the gastrointestinal tract (gastric, others), necrotizing enterocolitis (NEC) with perforation/peritonitis, meconium peritonitis, perforation of the Meckel diverticulum, atresia, malrotation, volvulus, gastroschisis, omphalocele, postabdominal surgery, or intussucsception. Peritonitis in neonates is most commonly associated with gastrointestinal tract perforations.

    7. Infections. Most common is congenital (CMV, toxoplasmosis, syphilis, and others) but can also be from fungal, viral (parvovirus, enterovirus), or bacterial infections.

    8. Inborn errors of metabolism. Glycogen storage disorders, lysosomal storage disorders, and galactosemia can all cause ascites. Examples include infantile free sialic acid storage disorder (ISSD), Salla disease, GM1 gangliosidosis and Gaucher disease, a1-antitrypsin deficiency.

    9. Cardiac abnormalities. Congestive heart failure and right-sided heart obstruction can cause ascites.

    10. Chromosomal causes. Turner syndrome and trisomy 21.

    11. Iatrogenic. Can occur from fluid from central venous catheters or intraperitoneal extravasation of total parenteral nutrition (TPN) from a umbilical vein catheterization-related vessel perforation. See Chapter 44.

    12. Hemoperitoneum (bloody ascites). Uncommon but can be nontraumatic (hepatoblastoma) or secondary to birth trauma (hepatic, splenic, or adrenal) or secondary to a ruptured internal organ. Splenic trauma can be associated with consumptive coagulopathy.

  2. As a therapeutic procedure, such as removal of peritoneal fluid from massive ascites or air from a pneumoperitoneum to aid in ventilation in a patient with cardiorespiratory compromise.

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II. EQUIPMENT

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Sterile drapes, sterile gloves, topical disinfectant such as povidone-iodine solution, sterile gauze pads, tuberculin syringe, 1% lidocaine, sterile tubes for fluid, a 10- to 20-mL syringe on a 3-way stopcock, safety engineered 22- or 24-gauge catheter-over-needle assembly (24 gauge for <2000 g, 22–24 gauge for >2000 g). Consider the use of ultrasound to guide needle placement.

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III. PROCEDURE

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  1. Contraindications and precautions. Paracentesis can be done with thrombocytopenia or coagulopathy if corrected before the procedure. With massive bowel distension, attempt to reduce distension with a nasogastric (NG) or rectal tube. Avoid surgical scar sites.

  2. Diagnosis of ascites. Ascites is usually diagnosed by clinical examination and ultrasound ...

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