The Pre-brief
Paracentesis is a safe procedure, but if the abdominal wall blood vessels are not identified with ultrasound, the patient is at risk for a serious bleeding complication.
Abdominal paracentesis is a relatively straightforward procedure performed for therapeutic drainage of intra abdominal ascitic fluid and/or to obtain a sample of fluid for an infectious or malignancy workup. Ultrasound is typically utilized to help identify a ‘pocket’ of fluid; an area with moderate fluid depth and enough space between the peritoneum and the underlying intestine. The curvilinear (abdominal) probe is used to measure fluid depth in the right and left lower quadrants in order to identify the ideal location for needle/catheter insertion and fluid drainage. Complication rates are reported to be as low as ~1-2%. Complication events include a dry tap, superficial bleeding, infection (0.5%), bowel perforation (0.8%), fluid leak, and arterial bleeding. Bleeding in itself is relatively rare carrying a risk of ~0.2% even in coagulopathic patients with INR >1.5 or platelet count <50 x109/L
However, if an artery or congested vein is punctured or lacerated during a paracentesis, the consequences can be catastrophic in patients with a bleeding diathesis, which have been reported in case reports. Anecdotally, I once cared for a patient with massive hemoperitoneum after a paracentesis was performed at another hospital.
Patients with cirrhosis can have many collateral vessels in the abdominal wall, but the vessel most susceptible to injury and leading to massive bleeding is the inferior epigastric artery. This artery sits 5-6 cm lateral to the midline and frequently near the ideal locations for a paracentesis in the right and left lower quadrants. The proceduralist must ensure this vessel is not in the path of the needle/catheter before starting the procedure. The linear (superficial) probe should be used for this. Here’s an abdominal probe ultrasound identifying an excellent pocket for drainage:
A mark was made at the center of the probe. The linear probe was then placed directly on the mark and the following image with color doppler was obtained:
The artery and corresponding vein are directly in the planned path of needle/catheter insertion. Obviously, had the linear probe not been used and the location of these vessels not identified, there was a high probability that one of these vessels would have been punctured, putting the patient at risk for hemorrhage.
The De-Brief
- Use the abdominal probe to identify the ideal location to perform a paracentesis for ascitic fluid drainage
- Use the superficial probe to ensure that there aren’t any abdominal wall blood vessels in the path of the proposed procedure site
References
Patel IJ, Rahim S, Davidson JC, Hanks SE, Tam AL, Walker TG, Wilkins LR, Sarode R, Weinberg I. Society of Interventional Radiology Consensus Guidelines for the periprocedural management of thrombotic and bleeding risk in patients undergoing percutaneous image-guided interventions—part II: recommendations: endorsed by the Canadian Association for Interventional Radiology and the Cardiovascular and Interventional Radiological Society of Europe. Journal of Vascular and Interventional Radiology. 2019 Jan 1.
Ennis J, Schultz G, Perera P, Williams S, Gharahbaghian L, Mandavia D. Ultrasound for detection of ascites and for guidance of the paracentesis procedure: technique and review of the literature. International Journal of Clinical Medicine. 2014 Nov 4;5(20):1277.
Millington SJ, Koenig S. Better with ultrasound: paracentesis. Chest. 2018 Jul 1;154(1):177-84.
De Gottardi A, Thévenot T, Spahr L, Morard I, Bresson–Hadni S, Torres F, Giostra E, Hadengue A. Risk of complications after abdominal paracentesis in cirrhotic patients: a prospective study. Clinical Gastroenterology and Hepatology. 2009 Aug 1;7(8):906-9.
Lam EY, McLafferty RB, Taylor Jr LM, Moneta GL, Edwards JM, Barton RE, Petersen B, Porter JM. Inferior epigastric artery pseudoaneurysm: a complication of paracentesis. Journal of vascular surgery. 1998 Sep 1;28(3):566-9.
I am an emergency physician and clinical ultrasound lead. I have also personally had lateral abdominal wall hematoma from inadvertent vascular damage. This is a really important pre-procedure check, Might be worth stating probe orientation for clips- are they both in long? Just putting colour on when you’re set up for insertion should prevent.majority.