CONTRAINDICATIONS
■ Relative: Coagulopathy (though even patients who have platelet levels
<50000/mm^3 and prothrombin times >20 seconds have very few
complications)
■ Absolute: Infection or engorged veins over site
TECHNIQUE
■ Patient is placed supine or in left lateral decubitus position. Sterile tech-
nique is used. Local anesthesia is applied at entry site. Ultrasound may be
used to confirm presence of ascites and avoid bowel injury, though “blind
taps” have a very low complication rate.
■ Possible sites of entry are 2 cm below the umbilicus in the midline or
4–5 cm cephalad and medial to the anterior superior iliac spine. Avoid the
inferior epigastric artery, which runs from the midpoint of the inguinal lig-
ament to the umbilicus.
■ An over-the-needle fenestrated catheter is inserted perpendicular to skin.
The “Z tract” method can be used wherein the skin is pulled ~2 cm caudad,
then the needle is inserted, and the skin is released when fluid flows from
needle. After the needle is removed, the catheter is taped to the skin and
connected to a vacuum bottle.
■ Fluid is routinely sent for cell count, culture, and Gram stain but can also
be sent for protein, glucose, LDH, amylase, albumin, TB culture, cytology,
triglycerides, and bilirubin.
■ When performing a therapeutic paracentesis, consider intravenous albumin
if volume of ascites removed exceeds 5 L. Hemodynamic compromise may
occur with removal of large amounts of fluid.
■ Intravenous albumin is also part of the treatment of patients with SBP.
COMPLICATIONS
■ Persistent leakage of fluid from site (which can be remedied by a single
suture), hematoma, perforation of vessels/viscera, peritonitis or abdominal
wall abscess
INTERPRETATION OFRESULTS
■ Peritoneal fluid containing >250 PMN/Lis used by many authorities as
presumptive evidence of SBP. However, other cutoffs have been described
including WBC count >250 WBC/L with >50% polymorphonuclear
leukocytes.
■ WBC count <250 WBC/L, with predominant mesothelial cells occurs
with cirrhosis.
■ WBC count >1000 WBC/L with variable cell types occurs with neoplasms.
Rectal Foreign Body Removal
INDICATIONS
■ All rectal foreign bodies (FB) should be removed when diagnosed.
CONTRAINDICATIONS
■ Severe abdominal pain or signs of perforation
■ Nonpalpable rectal FBs require surgical consultation.
■ Insufficient experience or equipment
PROCEDURES AND SKILLSReview medications for
patients receiving a
therapeutic paracentesis. A
low sodium diet and increased
doses of furosemide and
spironolactone are usually
indicated.