Paracentesis In Children

Parecentesis is defined as a procedure in which a needle or a catheter is inserted into the peritoneal cavity through the abdominal wall in order to remove the ascitic fluid. It may be for diagnostic or therapeutic reasons.

Indications

Diagnostic:

• Evaluation of new onset of ascites.
• Exclusion of Peritonitis.
• Assessment of clinical deterioration in known cirrhotic patients.

Therapeutic:

• Decompression of tense ascites in symptomatic patients ( dyspnea, abdominal discomfort, early satiety )

Contraindications
Almost all are relative contraindications.

• Coagulopathy: consider platelet transfusion for platelet count <50,000 and FFP for INR> 1.5
• Uncooperative patient: consider sedation
• Multiple surgical operations: consider surgical consultation.

Materials needed for the procedure

• Minor procedure tray,
• 18-22 gauge 1.5 inch catheter over needle assembly,
• Syring (10-30 ml for infants and small children; 20-60 ml for older children and adolescents),
• Sterile specimen containers,
• Blood culture bottles,
• Povidone-iodine solution,
• Pressure dressing,
• Sterile gloves

Procedure

1. Verify that child’s bladder is empty. Place child in supine position.

2. If there is doubt about the presence or position of ascites, or if the amount of ascites is small, abdominal ultrasound can be helpful in locating ascites during the procedure.

3. The entry site is usually the midline, 2 cm below the umbilicus. Alternatively, a site in the right or left lower quadrant, lateral to the rectus sheath, and 2 -3 cm above the superior illiac spine in the mid line can be used. Avoid the upper abdomen, collateral vessels and surgical scars.

4. Prepare child’s skin with povidone-iodine solution and apply sterile drapes. Use sterile technique throughout the procedure.

5. Raise a skin wheal with 1% lidocaine over the entry site.

6. With the catheter over needle assembly mounted on the syringe, advance the needle into the anesthetized area carefully while gently aspirating. Angling the needle slightly to one side once the skin has been entered minimizes leaking (Z track). Some resistance will be felt at the fascia. Once return of fluid is obtained, leave the catheter in place, remove needle, reattach syringe and aspirate. It may be necessary to reposition the catheter because of abutting omentum or bowel wall.

7. Aspirate the amount of fluid needed for testing (10-30 ml). Bedside inoculation of blood culture bottles with ascitic fluid increases sensitivity of cultures.

8. For a therapeutic tap, leave the catheter in place. In older children and adolescents the catheter can be connected to a suction bottle with tubing. In infants and young children , manually remove the fluid with a syringe and 3 way stop cock. In adults a large volume of paracentesis (5-10 L) can be safely removed over 60-90 minutes. Infants and small children often benefit from simultaneous administration of a colloid solution, such as albumin or fresh frozen plasma during fluid removal. Watch vital signs carefully during and following the procedure.

9. Remove the needle quickly and apply a pressure dressing.

10. Depending on the clinical picture , send samples for the following studies: albumin, total protein, amylase, lipase, glucose, LDH, urea and creatinine.

Complications

• Peritonitis
• Bowel perforation
• Intra-abdominal hemorrhage
• Abdominal wall hematoma
• Abdominal wall abscess
• Perforation of the bladder.
• Persistent leaking of ascitic fluid.