The Therapeutic Paracentesis- Tips for Treating the Pregnant Man
By Jason Hine
We’ve all seen ‘em. Those ascites patients who present to the ED for one reason- that big ol’ belly. Sometimes it’s painful- the distension and stretching causing pain, other times it’s the shortness of breath- that restrictive pattern of lung disease from abdominal distension or even the associated pleural effusions.
They’re uncomfortable and they come to you for help. “Tap me doc,” they’ll ask. Their hepatologist was closed or they forgot the appointment was this week. But they’ve got the wrong doc. The therapeutic paracentesis is a rare ED procedure, and largely for one reason- it takes too long. Of course, there’s the risk of hypotension and the coagulopathies, but really those are incredibly rare- and we’ll get into that. If we are honest with ourselves the real reason this procedure doesn’t get done is because of time.
They’ll bleed… or code… right?
No. Many of us have heard of the new(er) literature and paradigm change where screening labs are thought unnecessary before an ED paracentesis.[1,2] Even the American Association for the Study of Liver Disease (AASLD), which published practice guidelines in 2014, note “that routine tests of coagulation do not reflect bleeding risk” and site minor bleeding issues (abdominal wall hematoma) at a ~1% risk and serious bleeding at far less (<1/1,000). They go on to state that the routine correction of coagulation labs with blood products is not advisable.
What about the hypotension? This is also less common than we think. In fact, with volumes up to 5 liters, the AASLD states the use of post-para albumin may not be necessary, as rebound hypotension is rare.
So It Comes Down to Time
So great, they’re likely not going to bleed out or go to 60/palp. But I cant be stuck in the room with two hundred 60 cc syringes or fifty five vacutainers. And that’s why we did this video. It demos a quick, low resource means of taking the fluid off without condemning you (or your med student) to an hour and a half in the room. It utilizes something in every room in your ED- the wall suction. Take a look and let us know what you think.
Lin CH, Chen SC, Ko PC. Preprocedure coagulation tests are unnecessary before abdominal paracentesis in emergency departments. Hepatology. 2005 Feb;41(2):402-3.
Grabau CM, Crago SF, Hoff LK, Simon JA, Melton CA, Ott BJ, Kamath PS Performance standards for therapeutic abdominal paracentesis. Hepatology. 2004 Aug;40(2):484-8
Runyon B. Management of Adult Patients with Ascites Due to Cirrhosis: Update 2012. AASLD Practice Guidelines.