You’re caring for Jane, a 57 y.o. patient with liver cirrhosis who developed ascites and requires paracentesis. Before her paracentesis, you instruct her to:
A. Empty her bladder.
B. Lie supine in bed.
C. Remain NPO for 4 hours.
D. Clean her bowels with an enema.
Correct Answer: A. Empty her bladder.
A full bladder can interfere with paracentesis and be punctured inadvertently. The preferred site for the procedure is in either the lower quadrant of the abdomen lateral to the rectus sheath. Placing the patient in the lateral decubitus position can aid in identifying fluid pockets in patients with lower fluid volumes. Ask the patient to empty his or her bladder before starting the procedure.
Option B: Placing the patient in the lateral decubitus position can aid in identifying fluid pockets in patients with lower fluid volumes. Paracentesis is done in a lateral decubitus or supine position. The ascites fluid level is percussed, and a needle is inserted either in the midline or lateral lower quadrant (lateral to rectus abdominis muscle, 2 cm to 4 cm superomedial to anterior superior iliac spine). This positioning avoids puncture of the inferior epigastric arteries.
Option C: NPO is not necessary for the procedure. There are few absolute contraindications for paracentesis. Coagulopathy and thrombocytopenia (both very common in cirrhotic patients) are themselves not absolute contraindications as the incidence of bleeding complications from the procedure has been shown to be very low.
Option D: An enema is not necessary for the procedure. A bedside ultrasound should be used to identify an appropriate location for the procedure. Ultrasound can confirm the presence of fluid and identify an area with a sufficient amount of fluid for aspiration, thereby decreasing the incidence of both unsuccessful aspiration and complications.
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