139

Anne S. Roberts

A. Alfred Chahine

26 Abdominal Paracentesis

A. Indications

1. Therapeutic: To reduce intraabdominal pressure in

patients with massive ascites causing cardiorespiratory

compromise

2. Diagnostic: To aid in determining the etiology of neonatal ascites and/or peritonitis

a. Necrotizing enterocolitis with suspicion of

gangrene or perforation: Presence of fecal matter

or bacteria and white blood cells on a smear (1–3)

b. Hepatic ascites: Comparison of serum and ascitic

albumin levels, cell count, and culture in diagnosis

of spontaneous bacterial peritonitis (4,5)

c. Chylous ascites: Testing for triglycerides, cholesterol, and lymphocytes on cell count of the fluid (3,5)

d. Urinary ascites: Test for creatinine content (6)

e. Meconium peritonitis: Gross appearance of

ascites (7)

f. Biliary ascites: Test for bilirubin level

g. Pancreatic ascites: Test for amylase, lipase levels (8)

h. Congenital infections (cytomegalovirus, tuberculosis, toxoplasmosis, syphilis): Test for inclusion bodies, treponemes (5,9)

i. Inborn errors of metabolism (sialic acid storage disorders): Test for vacuolated lymphocytes

and free sialic acid (10)

j. Iatrogenic ascites from extravasation of fluid

from central venous catheters: Test for glucose

content

B. Contraindications

Coagulopathy is a relative contraindication; the procedure

may be performed with concomitant treatment of thrombocytopenia or coagulopathy, though controversy exists over

whether administration of blood products is necessary (4,11).

C. Equipment

1. 24- or 25-gauge catheter over a needle (e.g., Angiocath)

2. 5- or 10-mL syringe

3. Skin topical disinfectant (e.g., povidone–iodine,

chlorhexidine)

4. Sterile towels

5. Sterile gloves

6. Extension tubing

7. Three-way stopcock

8. Collection tubes and specimen containers for fluid

analysis

 Cell count and differential, culture, Gram stain, acidfast bacillus smear, cytology, total protein, albumin,

glucose, lactate dehydrogenase, amylase, bilirubin,

creatinine, blood urea nitrogen, electrolytes, specific

gravity, pH, cholesterol, triglycerides

9. Tuberculin syringe

10. Lidocaine (1%)

11. Dressing supplies

D. Technique

1. Obtain appropriate informed consent and time out

prior to procedure. Patient should be on cardiorespiratory monitor and have appropriate temperature support

(Chapter 3).

2. Place a soft support (“bump”) is placed under the supine

neonate’s left flank to allow as much of the fluid to drain

into a dependent position and allow the intestines to

float away from the right lower quadrant (Fig. 26.1).

3. Prepare the right lower quadrant with the disinfecting

solution and drape with sterile towels.

4. Select a point between the umbilicus and the anterior

superior iliac spine one third of the way from the anterior superior iliac spine. Avoid the midline to minimize

risk to the bladder and a patent umbilical vein, and

avoid previous surgical scars to minimize risk of bowel

injury. An infraumbilical position avoids the liver and

spleen.

5. Infiltrate the skin, muscles, and peritoneum with local

anesthetic using the tuberculin syringe.

6. Connect the 10-mL syringe to the 24-gauge catheter

and needle.

7. Direct the catheter toward the back at a 45-degree angle

(Fig. 26.2). The nondominant hand may be used to