Paracentesis, abdominal, ascites

Abdominal paracentesis is useful particularly when ascites is tense rapid drainage of 5 litres leads to prompt relief of discomfort and improves circulatory dynamics. Provided renal function is not compromised, extensive paracentesis is safe and can be used as an adjunct to diuretic therapy to shorten hospital stay. When more than 5 litres are drained it is customary to infuse colloid or albumin (6-8 g per litre of fluid removed) to prevent hypovolaemia. 

In adult patients with new-onset ascites as determined by physical exam or radiographic studies, abdominal paracentesis should be performed and ascitic fluid analysis should include a cell count with differential and a serum-ascites albumin gradient (SAG). If infection is suspected, ascitic fluid cultures should be obtained at the time of the paracentesis. The SAG can accurately determine whether ascites is a result of portal hypertension or another process. If the SAG is >1.1 g/dL, portal hypertension is present with 97% accuracy. If the SAG is <1.1 g/dL, with similar certainty the patient does not have portal hypertension. This is important because patients without portal hypertension will not respond to salt restriction and diuretics. The treatment of ascites secondary to portal hypertension is relatively straightforward and includes abstinence from alcohol, sodium restriction, and diuretics. This strategy is effective in approximately 90% of patients. Fifteen percent of patients will respond to dietary sodium restriction alone, and an additional 75% of patients will respond to the addition of diuretics. ... 

Adult patients admitted to the hospital with new-onset ascites should have an abdominal paracentesis performed to establish the serum-ascites albumin gradient, the ascitic fluid PMN count, and to obtain ascitic fluid cultures. Patients who drink alcohol should be strongly discouraged from further alcohol use. Sodium restriction to 2000 mg/ day, together with spironolactone and furosemide, is the main-... 

Consider large-volume paracentesis if evidence of abdominal compartment syndrome is secondary to tense ascites... 

Secondary bacterial peritonitis, ascitic fluid infection caused by a treatable intra-abdominal source, can masquerade as SBP and should be considered when multiple or atypical organisms are cultured, a very high ascitic fluid PMN count is seen, or in patients who fail to respond to appropriate antibiotic therapy. Uncomplicated SBP usually responds rapidly to appropriate therapy and the 48-hour PMN count, if obtained, is predictably lower than the initial count. In this setting a follow-up paracentesis revealing a PMN count that continues to rise despite antibiotic therapy can be helpful in detecting secondary peritonitis. ... 

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