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  • • Diagnostic sampling of ascitic fluid (eg, internal bleeding following blunt abdominal trauma, chylous ascites after surgery, rule out malignancy, identification of infectious organism in spontaneous bacterial peritonitis).

    • Therapeutic removal of the ascitic fluid (eg, chylous ascites, tense ascites, intestinal lymphangiectasia).

Absolute

  • • Unstable airway.

    • Hemodynamically unstable patient.

    • Intestinal perforation.

Relative

  • • Infection of the abdominal wall.

    • Coagulopathy (prothrombin time > 18 seconds).

    • Thrombocytopenia (platelet count < 100,000/mcL).

    • Recent intestinal tract surgery (< 1 month ago).

  • • Alcohol swabs, povidone-iodine.

    • 23-gauge and 21-gauge needles or angiocatheters with syringes.

    • Local anesthetic (eg, 1% lidocaine).

    • Large bore needle with plastic catheter.

    • Sterile containers for fluid collection.

    • Appropriate culture tubes for microorganisms.

  • • Pneumoperitoneum.

    • Perforation: Intestine, solid organs.

    • Bleeding.

    • Infection.

  • • Explain indication and risks to the patient and parents.

    • Inform the patient of the intention of the procedure.

  • • Supine or side.

  • • The preferred site is in the midline approximately one-third of the distance from the umbilicus to the symphysis pubis (Figure 28–1).

  • • In infants, the fluid may bulge laterally, and the paracentesis may be obtained laterally to that point.

Figure 28–1.

Anatomic landmarks and sites of entry.

Paracentesis

  • • The puncture site should be shaved, if necessary, and cleansed with povidone-iodine.

    • Inject local anesthetic, infiltrating the skin first and then penetrating into deeper layers.

    • A small 3-mm incision can be made with a scalpel to help insert the needle. Using Z-track technique, insert the tap needle 1–2 inches into the abdomen (Figure 28–2).

  • • Obtain a sample of fluid or withdraw as much fluid as necessary with a syringe (in case of therapeutic lavage) (Figure 28–3).

  • • Remove the needle and apply a pressure dressing to the puncture site.

    • If an incision was made, it may be closed using 1 or 2 stitches.

    • The ascitic fluid removed may be replaced 1:1 with 5% albumin IV.

Figure 28–2.

The Z-track. A: Needle is inserted perpendicular to skin while skin is pulled taut. B: Sagittal view. C: Alternatively, needle can be inserted at 45 degrees to skin and aimed caudally. D: Resultant Z-track (arrows).

Diagnostic Peritoneal Lavage

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• Diagnostic peritoneal lavage is usually performed by a surgeon to rule out internal bleeding following trauma.

  • • The puncture site should be shaved, if necessary, and cleaned with ...

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