ABDOMINAL PARACENTESIS

ABDOMINAL PARACENTESIS – Purpose, Indications, Contraindications, General Instructions, Routine Investigations, Preliminary Assessment, preparation of the Patient and Environment, Site and Position, Equipment, Procedure, Post-procedure Care and Complications

Abdominal paracentesis is defined as the removal of fluid from the peritoneal cavity.

Abdominal paracentesis or peritoneal tap is defined as the insertion of needle or cannula with trocar into the peritoneal space through the abdominal wall to remove peritoneal fluid.

PURPOSE

• To relieve pressure on the abdominal and chest organs if a transudate collects as a result of renal, cardiac, or liver diseases
• To study chemical, bacteriological and cellular composition of the peritoneal fluid for the diagnosis of diseases
• To drain an exudates in peritonitis
• To remove fluid and instill air to create artificial pneumoperitoneum as a treatment for pulmonary tuberculosis affecting the base of the lungs
• To remove blood or pus
• To use as a prelude to other procedures like X-ray, peritoneal dialysis or surgery

INDICATIONS

Diagnostic: to diagnose the nature of fluid, transudate or exudates, Koch’s ascites, spontaneous bacterial peritonitis and malignancy

Therapeutic: ascites with cardiopulmonary embarrassment, ascites refractory to medical line of treatment and ascites causing abdominal discomfort

CONTRAINDICATIONS

Primary: bleeding diathesis and severe jaundice with impending hepatic coma because tapping may precipitate hepatic coma

Secondary: multiple previous abdominal operations but can be done under ultrasound guidance and presence of dilated bowel

GENERAL INSTRUCTIONS

• Abdominal paracentesis should be done with strict aseptic technique to prevent introduction of infection into the peritoneal cavity
• Ask the patient to void 5 minutes before the procedure to prevent injury to the bladder
• Keep the patient warm and comfortable to prevent chills
• Withdrawing fluid should be done slowly and small quantity at a time
• Use a tapping needle or trocar of smaller gauge possible. This will reduce the puncture wound as small as possible and thereby reduce the chance of fluid leaking from the peritoneal cavity after the procedure is over
• The flow of fluid can be controlled by the application of clamps on the tubing
• The nurse should remain with the patient throughout the procedure to observe the patient’s general condition
• The puncture wound should be sealed immediately after the procedure to prevent infection and leakage of peritoneal fluid
• The specimens collected should be sent to the laboratory without delay

ROUTINE INVESTIGATIONS

• Specific gravity, cell count, bacterial count, protein concentrations, culture and acid test strain
• In most disorders, the fluid is clear and straw colored. Turbidity suggests infection
• Sanguineous fluid usually signals neoplasm or tuberculosis
• A protein concentration less than 3 g/100 ml suggests liver diseases or systemic disorders
• Higher protein content suggests an exudates cause such as tumor or an infection

PRELIMINARY ASSESSMENT

Check

• The doctors order for any specific precautions
• The general condition and diagnosis of the patient
• Self-care ability of the patient
• Condition of the abdomen
• Articles available in the unit

PREPARATION OF THE PATIENT AND ENVIRONMENT

• Explain the procedure to the patient and his relatives
• Obtain a written consent from the patient or relatives
• Prepare the skin as for a surgical procedure
• Empty the bladder just before the procedure
• Maintain privacy with screens
• Protect the bedding with a mackintosh and towel
• Arrange the article at the bedside

SITE AND POSITION

• Premediation: inj. Atropine sulfate 0.65 mg, intramuscularly half an hour procedure is given to the patient
• Selecting a site: the primary object of selecting a site is to avoid injury to the urinary bladder and other abdominal organs. In the flank at midpoint below anterior superior iliac spine and umbilicus
• Position: the patient is positioned in Fowler’s position supported by back rest and pillow near the edge of the bed

EQUIPMENT

An unsterile tray containing:

• Mackintosh and towel
• Sterile gloves and masks
• Tincture iodine, spirit and tincture benzoin
• Novocaine 1-2%/xylocaine 2%
• Adhesive tape and scissors
• Kidney basins, pint measure, bucket
• IV bottles, back rest and abdominal binder

A sterile tray containing:

• Sponge holding forceps
• Window towel, small bowels: 2, sponge
• Swabs, cotton and 2 ml syringe
• Subcutaneous needle
• Scalpel blade
• Trocar and cannula (Thompson’s ascites brocar and cannula)
• Suture materials: suture and skin needles, suture scissors, tissue forceps and artery forceps

PROCEDURE

• Wash hands thoroughly
• Position in Fowlers: this causes the fluid in the abdominal cavity to accumulate in the lower abdomen through gravity pull
• Assist the doctor in cleaning the site and giving local anesthesia
• Local anesthesia: 2% lignocaine is infiltrated into the skin, subcutaneous tissue, muscles and peritoneum
• Assist the doctor by providing towels and other required items
• Watch the vital signs and condition of the patient
• Wrap the binder tightly around the waist as fluid escapes. This prevents sudden change in pressure. Rapid change in pressure causes distention of abdominal veins, reducing blood in the heart. This may cause heart failure
• Collect the required amount in a pint measure or bucket
• Usually a pint to one filter of fluid is removed. Avoid rapid removal of fluid. Sudden withdrawal of a large quantity of fluid at one setting may change the intra-abdominal pressure
• After finishing withdrawal of fluid, seal the puncture wound with tincture benzoin and cover with a pad to prevent leakage of fluid

POST-PROCEDURE CARE

• Apply abdominal binder tightly from top to bottom. It helps maintain intra-abdominal pressure
• Monitor the patient’s general condition. Any change in the color, pulse, respiration and blood pressure should be reported immediately
• Examine the dressing at the puncture site frequently for any leakage, reinforce the dressing if leakage is present
• Provide analgesics, if there is pain
• The specimen collected should be sent in laboratory with labels and a requisition form
• Replace the articles after cleaning
• Wash hands thoroughly
• Record the procedure in the nurse’s record sheet

COMPLICATIONS

• Precipitation of hepatic coma
• Fainting, if large amount of fluid is removed too rapidly. This can be prevented by applying abdominal binder
• Peritonitis
• Perforation of viscous
• Depletion of proteins