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Paracentesis ascites evacuated

TECHNIQUE evacuated ascites paracentesis
home management of a complication of liver cirrhosis and neopasie
Author: Marin

The technique of paracentesis evacuated and a useful manual to continue to assist at home rather than hospitalized patients with ascites, most often due to peritoneal carcinomatosis or liver cirrhosis (Am J Gastroenterol 2006, 101 / 9: 1954-5; Br J Nurs 2006, 15 \\ 4: 212-19). Because of its practical importance, the NEJM 2006, 355/19, published an instructional video that demonstrates the technique can be downloaded from the website http://www.nejm.org/

A massive peritoneal fluid results in a bulbous abdomen tense and impeding diaphragmatic breathing, helps appearance of umbilical hernia and may be complicated by bacterial peritonitis, one from hepatorenal syndrome and hepatic encephalopathy.

therapy of ascites is based on low-salt diet (less than 0.5 grams of sodium daily), the restriction of water (1 liter / day if the serum sodium is less than 125 mEq / l), l ' use of diuretics, paracentesis evacuative repeated in the case of non- response to previous interventions, temporary restoration of colloid-osmotic pressure by infusion of albumin or plasma expanders in cases of severe hypoalbuminemia and hypovolemia ( NEJM 2004, 350: 1646 ).

diuretics are the first choice antialdosteronici as increasing the dose of spironolactone 100-300 mg / day (The Med Letter 2003, 1156). Patients should be monitored daily by noting the values \u200b\u200bof body weight, waist circumference and diuresis that can be supported by the rest letto.In case of massive ascites, the optimal weight loss with diuretic therapy should not exceed 500 grams / day if the patient has no edema and 1000 grams / day if you have edema, for reduce the risk of hypovolemia.

If after the first 4 days of therapy with 100-300 mg of spironolactone the patient has lost less than 2 kg, is added furosemide 25-50 mg / day and after another 4 days if the weight loss is less 2 kg to increase the dosage to 400 mg / day of spironolactone and 75-100 mg of furosemide.

ratio to maintain the association is 100 mg of spironolactone for every 40 mg of furosemide. Patients not responding to furosemide or torasemide can be responded to acid etacrinico.I diuretics should be reduced or suspended if weight loss exceeds 500 grams / day, or it appears with acute renal failure ipercreatininemia or in the case of hypokalemia or alteration of sensorio.Nelle ascites unresponsive to idrosodica restriction and diuretic therapy, paracentesis can be performed evacuated purpose decompression by removing up to a maximum of 5 liters at a time with any subsequent reinfusion of the albumin dose of 6-8 grams per liter of ascites removed or re-infusion of plasma expander in case of hypovolemia. The ascites, however, tends to recur quickly.

In the case of bacterial peritonitis, culture-documented examination of the ascites, the treatment of choice is represented by cefotaxime at a dose of 2 g intravenously or, in patients without signs of renal failure and encephalopathy, the fluoroquinolones.

All patients with cirrhosis should undergo staging according to the classification of Child-Pugh, a semi-annual ultrasound monitoring for early detection of hepatocellular carcinoma, to search for esophageal varices by endoscopy to prevent digestive bleeding with ligation Endoscopic variceal and / or 'use of beta-blockers and nitrates (Lancet 2003, 361, 9361: 952).

According to the guidelines of the Italian Association for the Study of Liver (AISF) in the case of liver cirrhosis are indications for paracentesis:
  • tense ascites;
  • ascites refractory to diuretic therapy.

are contraindications for paracentesis of the total volume of ascitic:

  • shock;
  • severe renal impairment;
  • severe portal-systemic encephalopathy;
  • severe alteration of hemostasis (platelet count less than 40.000/mm3 or prothrombin activity less than 40%).

The technique of paracentesis of ascites includes evacuative the following action sequence:

  • the patient is positioned supine in left lateral decubitus semi-close to the edge of the bed on which was placed a tarpaulin, placing a cushion in the lumbar support.
  • your doctor, wash your hands and wear disposable gloves, set out in the patient's left and find the lower left quadrant of the abdomen of the patient point between the middle and the outer third of the line located between the navel and the anterior superior iliac spine to the left.
  • The doctor disinfects the skin and local anesthesia practice (eg, vinyl chloride spray or EMLA cream).
  • Doctor G17 Push the needle cannula into the peritoneal cavity through the marked point and then connects the needle to the outflow pipe connected to the collection bag that is attached to the lower frame of the bed in order to the drainage for the fall of ascites.
  • The needle cannula is fixed with a patch to the abdominal skin.
  • The doctor may possibly connect a syringe to the 3-way stopcock cannula needle to aspirate the fluid that flows in order to carry out an examination biochemical, cytological and culture fluid ascites.
  • The patient is monitored during the emptying of ascitic, you adjust the speed of runoff and observed the filling of the bag until you reach the maximum amount set out to 5 liters, then the discharge tube is clamped with pliers.
  • The doctor removes the needle cannula and conduct a compressive sterile dressing.
  • The patient remains on bed rest, monitoring for at least one hour, your general condition, vital signs, particularly blood pressure and heart rate for the risk of hypovolemic shock, very unlikely for paracentesis with volume less than 5 liters.
  • In the case of volume or volume paracentesis of more than 5 liters, it is useful to give intravenous albumin or colloid plasma expander (6-8 grams per liter of ascites removed). The infusion rate should not exceed 16 g / h and 250 ml of albumin. / H to Haemaccel.
  • Patients with ascites should be regularly checked for albumin, creatinine, serum sodium and potassium.


This publication reflects the views and experiences of the author and do not necessarily those of Merck Sharp & Dohme Italy SpA