Indications
- Diagnostic — new-onset ascites (SAAG, cell count, culture)
- Diagnostic — suspected SBP (fever, abdominal pain, encephalopathy)
- Therapeutic — tense ascites causing respiratory compromise
- Therapeutic — refractory ascites failing diuretic therapy
- Malignant ascites — palliation of symptoms
- Chylous ascites — triglyceride level confirms diagnosis
- Pre-TIPS evaluation — ascites refractory to medical management
- Peritoneal carcinomatosis — cytology, chemical analysis
Technique and Fluid Analysis
- US guidance — mandatory; identify largest pocket, avoid vessels
- Left lower quadrant — preferred access (avoids cecum/appendix)
- 5 Fr pigtail or 14–18G paracentesis needle/cannula
- SAAG ≥1.1 — portal hypertension (cirrhosis, CHF, Budd-Chiari)
- SAAG <1.1 — non-portal cause (malignancy, TB, pancreatitis)
- PMN ≥250/mm³ — diagnostic of SBP regardless of culture
- Albumin 6–8 g/L drained — LVP (>5 L) to prevent PICD
- No routine FFP/platelets — INR not predictive of bleeding
Full Paracentesis Procedure Playbook
Ultrasound technique, needle selection, fluid analysis interpretation, and albumin dosing
Complications and Post-Procedure
- Bleeding — rare (<1%); US guidance reduces risk
- Bowel perforation — rare; Z-track technique reduces leak
- PICD — post-paracentesis circulatory dysfunction (LVP without albumin)
- Hepatorenal syndrome — triggered by inadequate albumin replacement
- Peritonitis — rare; sterile technique essential
- Catheter obstruction — omentum entrapment; reposition or flush
- Ascites leak — persistent drainage at puncture site
- SBP treatment — cefotaxime 2g IV q8h × 5 days; repeat tap at 48h