Background Information:

What are the other Names for the Procedure?

• Abdominal Paracentesis
• Abdominal Tap
• Paracentesis for Ascites

What is Paracentesis surgical procedure?

Paracentesis is a procedure that is usually performed to drain ascitic fluid that builds up within the peritoneal cavity of the abdomen. This accumulation of fluid within the abdomen can cause significant discomfort and difficulty in breathing in some individuals. The procedure is also commonly referred to as an Abdominal Tap.

There are two types of Paracentesis procedures:

• Diagnostic Paracentesis: This procedure is performed to diagnose the cause of fluid accumulation (ascites) within the peritoneal cavity of the abdomen
• Therapeutic Paracentesis: This procedure is performed to relieve the signs and symptoms due to accumulation of fluid (ascites) within the peritoneal cavity of the abdomen

A needle catheter is usually inserted into the abdominal (peritoneal) cavity and the fluid accumulated is removed. In case of a Diagnostic Paracentesis, the fluid is sent to the laboratory for further analysis such as cancer, liver failure, infection, etc.

The procedure can be performed either under ultrasound guidance or CT guidance to detect the area of fluid accumulation and visualize ease of access to the fluid pockets.

What part of the Body does the Procedure involve?

Both Diagnostic Paracentesis and Therapeutic Paracentesis procedures involve the abdominal cavity (peritoneal cavity).

Why is the Paracentesis surgical procedure Performed?

Paracentesis can be performed either for diagnostic purposes or for therapeutic purposes.

• In Diagnostic Paracentesis, the procedure is performed to determine the cause of fluid accumulation (ascites) within the peritoneal cavity of the abdomen
• In Therapeutic Paracentesis, the procedure is performed to relieve the abdominal pressure caused by fluid accumulation

Common reasons for performing a Diagnostic Paracentesis may include:

• To rule out the possibility of infection such as spontaneous bacterial peritonitis. Individuals with spontaneous bacterial peritonitis present signs and symptoms such as abdominal pain, gastrointestinal bleeding, altered mental status, dysfunction of liver function, dysfunction of liver function, decreased blood pressure (hypotension), and fever
• To determine the cause of fluid accumulation that may occur suddenly or over a period of months/weeks

Common reasons for performing a Therapeutic Paracentesis may include:

• To relieve the symptoms due to fluid accumulation within the abdomen such as difficulty in breathing, abdominal pain, and discomfort. In some individuals, large amounts of fluid can be drained using this procedure (sometimes over 5L of fluid)

Ascites may be caused by a variety of factors such as:

• Cancer (malignant ascitic fluid)
• An infection, such as bacterial peritonitis, causing acute peritonitis
• Inflammation (swelling) caused by a variety of conditions such as autoimmune disorders, acute pancreatitis, portal hypertension, etc.
• Abdominal injury
• Liver failure caused by a variety of conditions; most conditions causing liver failure are due to cirrhosis of the liver (scarring of the liver)

Contraindications for performing Paracentesis, but not limited to, include:

• Abdominal injury: Acute abdominal injury requiring immediate surgery is usually considered to be an absolute contraindication for performing Paracentesis
• Severely decreased platelet count in the peripheral blood, medically termed as very severe thrombocytopenia, with platelet count less than 20,000/μL is usually considered a limit that contraindicates the procedure
• Any clinical condition resulting in a decreased ability for blood clot (or coagulopathy) increases the chances of bleeding within the abdomen during the procedure, and hence is a contraindication. A lab test, called INR, can be used to determine the body’s ability to coagulate.  An international normalized ratio (INR) level greater than 2 is considered to be a contraindication 
• Individuals who have severe bowel distention may require extra precautions while performing the procedure
• Multiple previous abdominal operations results in adhesions (intra-abdominal adhesions) within the abdominal cavity makes the procedure more difficult to perform. These adhesions can also increase the risk for bowel injury during the procedure; and therefore, in some cases, the procedure may be contraindicated
• Pregnancy may be a contraindication to the procedure. Extreme caution may be required in pregnant women (absolute to midline procedure)
• Individuals, who have a distended bladder from a variety of conditions, need additional precautions. This is especially important when a distended bladder urine cannot be emptied with a Foley catheter (relative contraindication)
• If an individual has infection on the abdominal skin, then precaution must be taken to not insert a needle at the site of infection for performing a Paracentesis. This is considered to be a relative contraindication
• Severe hypoproteinemia, or low protein levels in blood, is a relative contraindication for performing Paracentesis
• Hepatomegaly and splenomegaly require extra precaution while performing the procedure

What are some Alternative Choices for the Procedure?

Before performing a surgical procedure, such as Paracentesis, other options to decrease the fluid accumulation may include:

• Low-sodium diet
• Administration of medication, such as diuretics, to flush out fluid accumulated within the abdomen

What are the Recent Advances in the Procedure?

Presently, there are no recent advances to the Paracentesis surgical procedure.

What is the Cost of performing the Paracentesis surgical procedure?

The cost of the Paracentesis procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused with a sudden inflow of information regarding the Paracentesis procedure and what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
• Also, if the procedure involves multiple steps or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

https://www.ncbi.nlm.nih.gov/books/NBK435998/ (accessed on 12/10/2022)

https://www.mskcc.org/cancer-care/patient-education/paracentesis-abdominal-tap (accessed on 12/10/2022)

https://endoscopycenterofredbank.com/procedure/paracentesis-for-ascites (accessed on 12/10/2022)

https://5minuteconsult.com/collectioncontent/30-156350/procedures/abdominal-paracentesis (accessed on 12/10/2022)

https://www.dovemed.com/common-procedures/procedures-laboratory/peritoneal-fluid-analysis/ (accessed on 12/10/2022)

Prior to Paracentesis surgical procedure:

How is the Paracentesis surgical procedure Performed?

The Paracentesis procedure is performed in the following manner:

• The individual is brought into the procedure room. Before the start of the procedure the individual may be asked to empty their bladder
• The healthcare staff may start an IV fluid in some individuals. This may help with fluid replacement when large amounts of accumulated fluid within the abdomen is removed through the Paracentesis procedure
• Equipment to monitor vital signs, such as blood pressure, body temperature, and pulse, may be used on case-by-case basis
• An ultrasound scan is performed to determine the areas of accumulated fluid and access points that will help remove most of the fluid within the abdominal cavity
• After the ultrasound scan study, a needle is inserted within the abdominal cavity carefully avoiding vital structures within the abdomen
• A numbing medication is usually given to decrease the pain from insertion of the needle after sterilizing the skin
• The insert needle is connected to a tube that leads into a container which collects the abdominal fluid. Often negative pressure suction is used to assist in the drainage of the fluid into the collecting container
• Close monitoring of the vital signs is often performed during the procedure since the individual’s blood pressure may drop
• After the procedure is performed the individual is monitored for a duration of time as determined by the healthcare provider

Where is the Procedure Performed?

Paracentesis is a relatively simple procedure that may be performed at the bedside. It can be performed in a physician's office, outpatient surgical center, or within a hospital setting.

Who Performs the Procedure?

The procedure may be performed by an internist, family practitioner, emergency department physician, radiologist, general surgeon, physician assistant, nurse practitioner, or an intensivist.

How long will the Procedure take?

• How long the Paracentesis will take depends on how much fluid is drained. It also depends on how fast the fluid is draining into the collecting container
• The procedure usually lasts less than an hour. After the procedure is completed, the individual may be asked to rest for observation

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables the healthcare provider in assessing the risks for the procedure and helps avoid complications.

• Provide medical history such as diabetes, hypertension, heart disease, etc. (if any)
• Provide a complete list of medications you are currently taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
• If you are allergic to any specific medication or food items
• If you are taking blood thinners, such as aspirin, warfarin, herbal supplements, or any other such medications
• Any medical or family history of bleeding disorders or blood clots
• If you have ever been diagnosed with blood clots in your leg (deep vein thrombosis) or lung (embolism of lung)
• Any unusual effects of anesthesia from prior surgery
• If you have a history of frequent bone fractures (this may affect bone-healing, if bones are involved as part of your procedure)
• A list of all previous surgical procedures you have undergone, like for example - removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.
• Information about any implanted electronic medical devices such as pacemakers, defibrillators, pain control devices, or deep brain stimulators for Parkinson’s disease or seizures
• Any joint implants, and if the surgeon who implanted them recommends preoperative antibiotics

What Preparations are needed, prior to the Procedure?

The physician performing the procedure will evaluate the patient prior to the procedure and discuss the details with risks for complications and obtain his/her permission (termed informed consent).

• Some medications increase a person’s chances of bleeding, and it may be recommended to discontinue them for a period of time, before the procedure is performed
• Blood tests may be performed to determine if there is a bleeding tendency or any other medical conditions that prevents the person from undergoing the procedure
• Blood work, glucose, and pregnancy tests (if applicable) will be undertaken per physician recommendations
• If anesthesia team is involved in the procedure, then they too will discuss details of anesthesia with risks for complications and obtain permission from the patient (informed consent)
• Avoid application of any deodorant or topical medicines on the area, prior to the procedure
• It is advisable to quit smoking and the use of any nicotine based products, for a while, before the procedure
• Consumption of alcoholic drinks must also be avoided for a period of time, as instructed
• Generally, the patient is told to eat, as they are awake for the procedure
• Individuals with diabetes, hypertension, or other cardiac conditions, are required to discuss these (including medications being taken) with their attending physician well in advance
• For individuals with diabetes, it is important that the blood sugar stays within the normal range; if not, their diabetologist may have to control blood sugar by recommending insulin and/or a combination of oral medicines

Pregnant women and individuals with severe underlying sicknesses are advised to inform the surgeon or staff of their health status.

• Your doctor or nurse will talk to you about what you are allowed to eat before your procedure
• Prior to the procedure, the patient may be asked to voluntarily empty his/her bladder, or the healthcare provider may use a Foley catheter to do so

What is the Consent Process before the Procedure?

The physician will obtain permission for the Paracentesis procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is the approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

In case of minors and individuals unable to give informed consent, the parent or legal guardian or next of kin can sign the consent for the procedure.

What Tests are needed, before the Paracentesis surgical procedure?

In many instances abdominal radiological studies are performed to determine the quantity of fluid accumulated and study other abnormalities within the abdominal cavity.

• Radiological studies may include ultrasound of abdomen, CT scan of abdomen, or MRI scan of the abdomen
• Blood test to determine any bleeding disorders and platelet count may be performed in some individuals

What are some Questions for your Physician?

Some of the questions that you might ask your healthcare provider are as follows:

• What is a Paracentesis procedure?
• Why is this procedure necessary? How will it help?
• How soon should I get it done? Is it an emergency?
• Who are the medical personnel involved in this procedure?
• Where is the procedure performed? 
• What are the risks while performing the procedure?
• What are the complications that might take place during recovery?
• How long will it take to recover? When can I resume normal work?
• How many such procedures have you (the physician) performed?
• Are there any follow-up tests, periodic visits to the healthcare facility required, after the procedure?
• What are the costs involved?

During the Paracentesis surgical procedure:

What kind of Anesthesia is given during the Procedure?

• Usually, local anesthesia to the skin is administer at the site of needle or catheter insertion
• In very rare cases, general anesthesia may be required, especially in children
• In some individuals, medications for sedation may be used to relieve anxiety

How much Blood will you lose, during the Procedure?

There may be minimal to no blood loss involved during the Paracentesis procedure.

What are the possible Risks and Complications during the Paracentesis surgical procedure?

There are general factors that increase one’s risk of getting complications during the Paracentesis procedure, which include:

• Obesity: Generally, the greater the degree of obesity, the greater the surgical risk
• Smoking: The longer the smoking history (in pack years smoked), the greater the surgical risk
• Advancing age
• Poorly-controlled diabetes, as evidenced by a high hemoglobin A1c and a high fasting glucose
• Poorly-functioning kidney, as evidenced by increased BUN (blood urea nitrogen) and blood creatinine
• Poorly-functioning liver, as evidenced by increased blood liver function tests
• Hypertension (increased blood pressure), especially if it is poorly controlled
• Poor nutritional status (malnutrition with mineral and vitamin deficiencies)
• Poor lung function, as evidenced by abnormal lung function tests
• History of bleeding disorders
• Poor immune system due to a variety of causes

Some of the possible risks and complications that may arise during a Paracentesis procedure include:

• Injury to the neighboring structures
• Bowel perforation: Perforation of the bladder, small intestine, large intestine (colon), and stomach (which is emptied before the procedure to decrease the risk)
• Injury to major blood vessels within the abdomen during catheter insertion may occur 
• Loss of catheter or guide wire in the peritoneal cavity
• Injury to the skin at the site of the catheter due to hematoma formation 
• Bleeding within the abdominal cavity can cause accumulation of blood, resulting in a condition called pneumoperitoneum
• Infection may cause abdominal peritonitis
• The abdominal accumulated fluid may leak from the puncture site of the catheter insertion 
• Decreased blood pressure can occur when large amounts of fluid are drained, resulting in a condition called post-Cervical Cerclage hypotension
• Electrolyte imbalance may occur if a large amount of fluid is drained. Monitoring of electrolytes is important to prevent such an electrolyte imbalance. Large amounts of fluid drainage may result in a condition called  dilutional hyponatremia
• Discomfort
• Need for further procedures

Please note that the complications and risks that may arise during the procedure are additionally governed by factors such as prior significant health issues.

What Post-Operative Care is needed at the Healthcare Facility after the Paracentesis surgical procedure?

Post-procedure, the patients may need close monitoring by the healthcare provider as it can be associated with decreased blood pressure (hypotension), bleeding (hemoperitoneum), and leakage of fluid from the catheter insertion point.

Following the procedure, the patient is advised rest for a short period and closely monitored. The healthcare provider may further advise you to get up slowly (or with assistance), since hypotension may cause lightheadedness resulting in unexpected falls

After the Paracentesis surgical procedure:

What are the possible Risks and Complications after the Paracentesis surgical procedure?

• Depending on the cause, the ascitic fluid may re-accumulate in the abdomen
• There may be electrolyte imbalance resulting from large fluid removal during the Paracentesis procedure
• Individuals who have malignant ascitic fluid accumulation may need frequent procedures for comfort care

Paracentesis is generally a safe procedure, but rarely complications may occur that include:

• Leakage of ascitic fluid from the site of cannula insertion
• Bleeding within the abdominal cavity 
• Infection within the abdomen causing peritonitis
• Insertion of the needle can inadvertently perforate bowel walls and blood vessels 
• Large amount of fluid removal may result in decreased blood pressure (hypotension)

What is the Prognosis after the Surgery?

The prognosis depends upon the cause of fluid accumulation. In individuals, when the procedure is performed for therapeutic reasons, the fluid removal can give immediate relief and improve some of the signs and symptoms caused by fluid accumulation.

In individuals with fluid accumulation occurring from a malignancy, repeated procedures may be required which may adversely affect one’s quality of life.

When do you need to call your Physician?

Do contact your physician or call 911 (or your local emergency number) based on the seriousness of any of the following symptoms:

• Sudden onset of abdominal pain 
• Pain and redness at the site of catheter/needle insertion
• Fever with chills
• Difficulty in breathing
• Leakage of fluid from the abdomen at the site of needle insertion
• Bleeding from the surgical wound
• Nausea and vomiting
• Signs of infection
• Severe fatigue
• Dizziness

What Post-Operative Care is needed at Home after the Paracentesis surgical procedure?

Your doctor will give you instructions on how to take care of the bandage and how to keep the wound clean. You may need to make changes in eating and drinking habits such as:

• Dietary restrictions, especially low-salt diet, as recommended by a healthcare provider
• Consume liquids as recommended by the healthcare provider 
• In some instances, medications, such as water pills, may be prescribed
• Monitor the site of needle insertion for signs of infection and bleeding (also for leakage of fluid from the abdomen)
• Pain medication may be prescribed, as needed
• Use a cold pack over the dressing to decrease swelling and bleeding risk. Follow the written guidelines on this, and all other post-operative care instructions provided
• Resume showering, but keep the dressing dry and protected 
• Replace dressing after showering, as instructed
• Take the prescribed medications following the procedure
• Avoid any strenuous activity for a period recommended by the physician
• Do not drive (post-procedure) for a period of 24 hours
• Avoid smoking or drinking alcohol post-procedure
• Continue old, prescribed medications after checking with the healthcare provider

Contact the concerned healthcare provider if there are any questions regarding one’s care.

How long does it normally take to fully recover, from the Procedure?

Paracentesis is usually a simple procedure and individuals are known to recover rapidly following fluid removal.

• The duration of rest and activity levels may be determined on a case-by-case basis.
• In a majority of cases, your healthcare provider may advise you to resume normal activities within 24 hours

Additional Information:

What happens to tissue (if any), taken out during the Procedure?

The drained ascitic fluid is sent to a laboratory for testing, in order to check for several parameters of the fluid and understand the cause of fluid accumulation. There are several tests that can be performed using the abdominal fluid that has been removed.

The following characteristics of the fluid may be evaluated:

• Appearance: Color, turbidity, and other visual properties
• Alkaline phosphatase: Enzyme associated with liver and gallbladder function
• Glucose
• Presence of microorganisms: Indicated by a Gram stain, acid-fast stain, and amylase levels
• Red blood cell and white blood cell counts
• Cytology: Scanning for the presence of abnormal-looking cells

Following lab analysis, the fluid is later disposed as per the standard medical procedure.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

• The samples/tissue is processed in the laboratory under a pathologist's supervision
• Slide(s) are prepared once the tissue is processed and this is examined by a pathologist and a pathology report issued
• Depending on the complexity of the case, issue of the report may take anywhere between 4-24 hours

Who will you receive a Bill from, after the Paracentesis surgical procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility, and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

• The physician's office, outpatient surgical center, or hospital
• The concerned healthcare provider(s)
• A radiologist
• A pathologist
• The laboratory at which the specimens are processed

The patient is advised to inquire and confirm the type of billing before the Paracentesis procedure is performed.