Chapter 33

1. Indications

1. To obtain peritoneal fluid for diagnostic tests to determine the cause of ascites. Ascites can be caused by or associated with necrotizing enterocolitis with perforation; biliary, urinary, chylous, or meconium peritonitis; iatrogenic or congenital infections; or inborn errors of metabolism.

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

2. Equipment. Sterile drapes, sterile gloves, povidone-iodine solution, sterile gauze pads, sterile tubes for fluid, a 10-mL syringe, and a 22- or 24-gauge catheter-over-needle assembly (24 gauge for infants weighing <2000 g, 22–24 gauge for infants weighing >2000 g).

3. Procedure

1. The infant should be supine with both legs restrained. To restrict all movements of the legs, a diaper can be wrapped around the legs and secured in place.

1. Choose the site for paracentesis. The area between the umbilicus and the pubic bone is not generally used in neonates because of the danger of perforating the bladder or bowel wall. The sites most frequently used are the right and left flanks. A good rule is to draw a horizontal line passing through the umbilicus and select a site between this line and the inguinal ligament (Figure 33–1).

1. Prepare the area with povidone-iodine in a circular fashion, starting at the puncture site.

1. Put on sterile gloves, and drape the area.

1. Infiltrate the area with anesthesia (lidocaine 0.5–1%) (see Chapter 69).

1. Insert the needle at the selected site. A "Z-track" technique is usually used to prevent persistent leakage of fluid after the tap. Insert the needle perpendicular to the skin. When the needle is just under the skin, move it 0.5 cm before puncturing the abdominal wall.

1. Advance the needle, aspirating until fluid appears in the barrel of the syringe. Then remove the needle and aspirate the contents slowly with the catheter. It may be necessary to reposition the catheter to obtain an adequate amount of fluid. Once the necessary amount of fluid is taken (usually 3–5 mL for specific tests or enough to aid ventilation), remove the catheter. If too much fluid is removed or if it is removed too rapidly, hypotension may result.

1. Cover the site with a sterile gauze pad until leakage has stopped.

4. Complications

1. Hypotension. Hypotension is caused by removing too much fluid or removing fluid too rapidly. To minimize this possibility, take only the amount needed for studies or what is needed to improve ventilation. Always remove fluid slowly.

1. Infection. The risk of peritonitis is minimized by using strict sterile technique.

1. Perforation of the intestine. To help prevent perforation, use the shortest needle possible and take careful note of landmarks (see Section III, B). If perforation occurs, broad-spectrum antibiotics may be indicated with close observation for signs of infection.

1. Perforation of the bladder. Perforation of the bladder is normally self-limited and requires no specific treatment.

1. Persistent fluid leak. The Z-track technique (see Section III, F) usually prevents the problem of persistent leakage of fluid. Persistent fluid leaks may have ...

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