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Complications and technical problems of paracentesis in cirrhotic patients are infrequent. However, the severity and the incidence of these events and their risk factors have not been assessed prospectively.
Cirrhotic patients (n = 171) undergoing paracentesis were included. Of the 515 paracenteses, 8.8% were diagnostic, and 91.2% were therapeutic....
Contexts in source publication
Context 1
... performed 515 abdominal paracenteses in 171 patients with a mean age of 59.6 years. The characteristics of the study population are presented in Supplementary Table 1. ...Context 2
... were 5.6% of procedures with technical problems. The characteristics and incidence are described in Table 1. Absence of ascitic fluid at the first puncture and interruption of ascites flow during the procedure often required a second puncture. ...Citations
... After receiving both an ED-performed and interventional radiology-performed paracentesis, one patient (1.2%) required red blood cell (RBC) transfusion; a prior retrospective study of 3,116 ultrasound-guided paracenteses performed by radiologists observed hemorrhage requiring RBC's or angiogram in 0.19% [6]. The most common complication was ascites leak (5.8%, 5/86), similar to the 5.0% leak rate reported in a prospective study mostly without using ultrasound [10]. We agree that performing the recommended "z-track" technique (where the non-dominant hand is used to put tension on the skin during puncture to decrease postprocedure leaking) might be more difficult when that hand is also holding the ultrasound probe [4,8]. ...
Background: Emergency physicians commonly perform ultrasound-assisted abdominal , using point of care ultrasound (POCUS) to identify and select a site for needle insertion. However, ultrasound-guided has the benefit of real-time needle visualization during the entire procedure. Our objective was to characterize the performance of emergency physician-performed ultrasound-guided using POCUS, their ability to achieve good in-plane needle visualization, and factors associated with procedural success. Methods: A POCUS database was retrospectively reviewed for examinations where abdominal was performed by an emergency physician at two academic urban emergency departments over a six-year period. Medical records were reviewed for demographics, presenting history, complications, and hospital course. Descriptive statistics were used to summarize the data. Results: 131 patients were included in the final analysis. The success rate for ultrasound-guided was 97.7% (84/86, 95% CI 92-100%) compared to 95.6% (43/45, 95% CI 85-99%) for ultrasound-assisted (p = .503). 58% (50/86) demonstrated good in-plane needle visualization; 17% (15/86) had partial or out-of-plane visualization; and 24% (21/86) did not demonstrate needle visibility on their saved POCUS images. All four procedural failures were performed by first- or second-year residents using a transducer, while all procedures using a linear transducer were successful. The most common complications were leak, infection at the site, and minor bleeding. Conclusions: Emergency physicians with training in real-time needle guidance with ultrasound were able to use POCUS to perform ultrasound-guided in the emergency department with a high success rate and no fatal complications. Based on our experience, we recommend performing ultrasound-guided using a linear transducer, with attention to identifying vessels near the procedure site and maintaining sterile technique.
... Paracentesis is a generally well-tolerated procedure. Adverse events are estimated at 1% and include infection, post-procedural leakage of ascitic fluid, abdominal wall hematoma, bowel perforation, and intraperitoneal hemorrhage [1,[4][5][6][7][8][9][10][11][12][13][14]. There are additional intraprocedural concerns such as the aspiration of intestinal wall or omentum into the centesis catheter, or the placement of the catheter tip within the abdominal soft tissue. ...
Paracentesis is a procedure routinely performed at the bedside in the evaluation and management of ascites. While point of care ultrasound (POCUS) assistance during paracentesis is known to reduce the risk of procedure-related complications, intraprocedural POCUS to overcome commonly occurring issues, such as obstructed flow through the centesis catheter, remain poorly described. In this report, we present two cases in which bowel adhered to the catheter during paracentesis. POCUS was used in an attempt to restore flow. Based on our literature review and procedural experience, we propose an algorithm to surmount this routinely encountered problem.
... La paracentesis proporciona alivio temporal de los síntomas en un 90 % de los pacientes [9], sin embargo, este procedimiento no altera la etiopatogenia para el continuo desarrollo de la ascitis [10]; se han descrito, además, complicaciones debido a punciones repetidas y un riesgo de peritonitis secundaria, perforación intestinal, hipotensión y hemorragia [11]. Caldwell [12] realizó una búsqueda bibliográfica de estudios publicados en los últimos 15 años, que reportaron la colocación de un catéter peritoneal tunelizado en pacientes con ascitis crónica. ...
Introducción: la ascitis refractaria puede ser una complicación frecuente en el síndrome nefrótico (SN), existen casos reportados del uso de un catéter tunelizado de diálisis peritoneal en pacientes con cirrosis o neoplasias abdominales. Se presenta el caso de un paciente con SN en quién se utilizó un catéter para diálisis peritoneal (DP) para manejo de la ascitis refractaria. Objetivo: mostrar que el catéter peritoneal puede ser considerado como una alternativa para el manejo de la ascitis refractaria en pacientes con síndrome nefrótico. Presentación del caso: paciente varón de 19 años, sin antecedentes patológicos, cursó con edema progresivo y alteración de la función renal. Se evidenció síndrome nefrótico con anasarca y evolucionó con empeoramiento de la función renal ingresando a hemodiálisis de soporte. Se realizó biopsia renal: podocitopatía, glomerulopatía colapsante. Se inició tratamiento con corticoterapia, mejorando la función renal hasta suspender la hemodiálisis, pero presentó ascitis refractaria al tratamiento médico, por lo que se realizó paracentesis evacuatoria en reiteradas ocasiones. Se decidió colocación de catéter peritoneal tunelizado para el manejo de la ascitis refractaria. La ascitis fue disminuyendo progresivamente hasta el retiro del catéter peritoneal. Discusión y conclusión: el uso de catéter tunelizado de diálisis peritoneal es una opción de manejo efectiva en casos de síndrome nefrótico con ascitis refractaria.
... Major complications were defined based on prior literature. [5][6][7][8][9] All interns received a post-rotation survey to obtain both quantitative and qualitative feedback. This study was reviewed by the Investigational Review Board of the University of Texas Health San Antonio and was deemed to be non-research (Protocol Number: 20220913NRR). ...
Background
Lack of experienced faculty to supervise internal medicine (IM) residents is a significant barrier to establishing a medical procedure service (MPS).
Aim
Describe the development and 10-year outcomes of an MPS led by IM chief residents.
Setting
University-based IM residency program affiliated with a county and Veterans Affairs hospital.
Participants
Categorical IM interns ( n =320) and 4 th -year IM chief residents ( n =48) from 2011 to 2022.
Program Description
The MPS operated on weekdays, 8 am–5 pm. After training and sign-off by the MPS director, chief residents trained and supervised interns in ultrasound-guided procedures during a 4-week rotation.
Program Evaluation
From 2011 to 2022, our MPS received 5967 consults and 4465 (75%) procedures were attempted. Overall procedure success, complication, and major complication rates were 94%, 2.6%, and 0.6%, respectively. Success and complication rates for paracentesis ( n =2285) were 99% and 1.1%, respectively; 99% and 4.2% for thoracentesis ( n =1167); 76% and 4.5% for lumbar puncture ( n =883); 83% and 1.2% for knee arthrocentesis ( n =85); and 76% and 0% for central venous catheterization ( n =45). The rotation was rated 4.6 out of 5 for overall learning quality.
Discussion
A chief resident–led MPS is a practical and safe approach for IM residency programs to establish an MPS when experienced attending physicians are unavailable.
... According to the authors, major complications were more due to therapeutic paracentesis other than diagnostic paracentesis. Infection, bleeding, and ascites fluid leakage were commonly reported complications (26). In another study, the side effects of paracentesis therapy were evaluated in adults. ...
Background:
Large-volume paracentesis has become the first treatment choice for patients with severe and refractory ascites. The studies have reported several complications after therapeutic paracentesis. But there are few published data on the complications with or without Albumin therapy. We aimed to analyze the safety and complications of large-volume paracentesis in children with or without albumin therapy.
Methods:
This study was conducted on children with severe ascites with chronic liver disease who underwent large-volume paracentesis. They were divided into albumin-infused and albumin non-infused groups. In the case of coagulopathy, no adjustment was made. Albumin was not administered after the procedure. The outcomes were monitored to evaluate the complications. To compare two groups, a t-test was utilized, and the ANOVA test was used to compare several groups. If the requirements for using these tests were not met, Mann-Whitney and Kruskal-Wallis tests were applied.
Results:
Decreased heart rate was observed in all time intervals and was meaningful six days after paracentesis. MAP also decreased statistically at 48 hours and six days after the procedure (P < 0.05). Other variables did not show any meaningful change.
Conclusion:
Children having tense ascites with thrombocytopenia, prolonged PT, Child-Pugh class C, and encephalopathy can undergo large-volume paracentesis without any complication. Albumin administration before the procedure in patients with low levels of Albumin (<2.9) can effectively overcome the problems of tachycardia and increased mean arterial pressure. There will be no need for Albumin administration after paracentesis.
... Data on patients with abnormal coagulation profiles (INR > 1.5 and/or platelet counts < 50000/μL) indicate that paracentesis[15,76,77] and thoracentesis [78][79][80][81] pose a very low risk for major bleeding. ...
Cirrhotic patients with severe thrombocytopenia are at increased risk of bleeding during invasive procedures. The need for preprocedural prophylaxis aimed at reducing the risk of bleeding in cirrhotic patients with thrombocytopenia who undergo scheduled procedures is assessed via the platelet count; however, establishing a minimum threshold considered safe is challenging. A platelet count ≥ 50000/μL is a frequent target, but levels vary by provider, procedure, and specific patient. Over the years, this value has changed several times according to the different guidelines proposed in the literature. According to the latest guidelines, many procedures can be performed at any level of platelet count, which should not necessarily be checked before the procedure. In this review, we aim to investigate and describe how the guidelines have evolved in recent years in the evaluation of the minimum platelet count threshold required to perform different invasive procedures, according to their bleeding risk.
... 9 Abdominal paracentesis is a simple bedside procedure in which a needle is inserted into the peritoneal cavity, commonly under ultrasound guidance, and ascitic fluid is removed. Serious complications from abdominal paracentesis are uncommon, but a number of complications have been described, such as ascitic fluid leak, which represents the most common complication, 10 bleeding, 8,10 bowel perforation, infection and electrolyte imbalance. 10,11 Mortality after paracentesis is exceedingly rare. ...
... Serious complications from abdominal paracentesis are uncommon, but a number of complications have been described, such as ascitic fluid leak, which represents the most common complication, 10 bleeding, 8,10 bowel perforation, infection and electrolyte imbalance. 10,11 Mortality after paracentesis is exceedingly rare. 7,10,12 Paracentesis is typically performed by passing a needle and catheter through the abdominal wall in the left lower quadrant. ...
Abdominal paracentesis is a common and safe procedure used to remove ascitic fluid from the body. It is performed in both the inpatient and outpatient setting and can be used for both diagnostic and therapeutic purposes. The most common complications of this procedure include a persistent fluid leak, an infection from the puncture site and an abdominal wall hematoma. The finding of sudden-onset massive genital swelling is a rare, and only occasionally reported, complication of a paracentesis. This article will discuss the case of a 58-year-old male with decompensated liver cirrhosis who presented with sudden-onset scrotal and penile swelling within 12 h after a paracentesis. After ruling out other causes of scrotal swelling, it was concluded that this is likely a complication of the recent paracentesis. The scrotal swelling was treated with conservative management including oral diuretic therapy and scrotal elevation, and the patient showed significant improvement in symptoms in 2 days. The cause of post-paracentesis scrotal edema is not widely studied; however, it is hypothesized to be caused by a fistula tract that forms between the peritoneal cavity and the Camper's and Scarpa's fascia which causes fluid to collect in the scrotum.
... The highest probabilities of complications were observed in patients with advanced liver disease (Child-Pugh C) [15]. Lin demonstrated a high risk of hemorrhage (2.99%) in patients with acute or chronic liver disease and that low fibrinogen levels were an independent predictor of bleeding in patients with MELD > 25 [10]. ...
Paracentesis is a validated procedure for diagnosing and managing ascites. Although paracentesis is a safe procedure with a 1–2% risk of complications such as bleeding, it is necessary to inform the patient about the possible adverse events. We would like to share our experience with two cases of bleeding after paracentesis. In our unit, two major hemorrhagic complications occurred in 162 procedures performed over the year 2020 (frequency of bleeding complications: 1.2%). We report two clinical cases of post-paracentesis abdominal wall hematomas. Despite a similar clinical presentation, the management approach was different: in the first case, embolization of the epigastric artery supplying the hematoma was performed. In the second case, conservative treatment was adopted. Our report aims to provide food for thought about a potentially challenging hemorrhagic complication, even with the risk of adverse outcomes.
... One of the complications of this simple bedside procedure is ascitic fluid leak. Post-paracentesis ascitic fluid leak occurs in around 5% of patients undergoing paracentesis 4 . Leaks can occur if a Z-tract has not been properly performed during the procedure, or if a large-bore needle is used 5 . ...
Background
Ascites is the most common complication of decompensated cirrhosis of liver requiring paracentesis for diagnostic and therapeutic purpose. Ascitic fluid leak can develop after paracentesis in patients with cirrhosis leading to significant morbidity if persistent. We aimed to study the incidence and predictors of post-paracentesis leak in patients with ascites.
Methods
In this prospective study, patients with cirrhosis undergoing therapeutic paracentesis were followed up and those who developed persistent leak were include as cases. Controls were randomly selected in a 2:1 ratio from the group of patients who did not develop leak. Clinical and laboratory parameters were compared between the two groups.
Results
A total of 256 patients underwent 1126 session of therapeutic abdominal paracentesis over a period of 14 months. Post-paracentesis leak was seen in 55 (4.8%) patients while only 20 (1.7%) patients had persistent leak. The management of leak was in a stepwise manner initially with tincture benzoine with tight dressing followed by topical cyanoacrylate adhesive followed by autologous blood patch in those not responding. Patients who had persistent leak had higher proportion of patients with parietal edema, higher PT-INR and Child-Pugh score and lower mid-upper arm circumference, short physical performance battery score and hand-grip strength. On multivariate analysis, only presence of parietal edema was an independent predictor of post-paracentesis persistent leak (Odds ratio 10.35, 95% confidence interval 1.61 – 66.54, p = 0.014).
Conclusion
Persistent leak after paracentesis develops in a minority of patients with cirrhosis. Presence of parietal edema is a risk factor for persistent leak. Majority of these patients can be managed in a stepwise approach.
... In other studies, proportions of definite extrapulmonary tuberculosis were lower with 4%-24% [6,7]. The absence of complications after invasive procedures in our and other studies [23][24][25][26] motivates the use of ultrasound-guided invasive procedures to increase the proportion of definite tuberculosis. This is of epidemiological importance, especially in the context of drug resistance, and is associated with higher survival in HIV-positive patients with extrapulmonary tuberculosis [6]. ...
Background:
Patients with suspected extrapulmonary tuberculosis are often treated empirically. We hypothesized that extended Focused Assessment of Sonography for HIV and Tuberculosis (eFASH), in combination with other tests, would increase the proportion of correctly managed patients with suspected extrapulmonary tuberculosis.
Methods:
This trial in adults with suspected extrapulmonary tuberculosis was performed in a rural and an urban hospital in Tanzania. Participants were randomised 1:1 to intervention or routine care, stratified by site and HIV status. All participants received a clinical evaluation, chest X-ray, sputum Xpert MTB/RIF, and urine Xpert MTB/RIF Ultra. The intervention was a management algorithm based on eFASH plus microbiology, adenosine deaminase (ADA) and chest X-ray. The primary outcome was the proportion of correctly managed patients. Presence of positive microbiology or ADA defined definite tuberculosis. An independent endpoint review committee determined diagnoses of probable or no tuberculosis. We evaluated outcomes using logistic regression models, adjusted for randomisation stratification factors.
Results:
From 09/2018 to 10/2020, 1,036 patients were screened and 701 randomised (350 intervention, 351 control). 251 (72%) intervention participants had a positive eFASH. 258 (74%) intervention and 227 (65%) control participants were initiated anti-tuberculosis treatment at baseline. More intervention participants had definite tuberculosis (n = 124, 35%) compared to controls (n = 85, 24%). There was no difference between groups for the primary outcome (intervention 266/286 (93%); control: 245/266 (92%); odds ratio 1.14 (95% confidence interval 0.60-2.16, p = 0.68)). There were no procedure-associated adverse events.
Conclusion:
eFASH did not change the proportion of correctly managed patients, but increased the proportion of definite tuberculosis.
