Paracentesis evacuadora tecnica pdf

La paracentesis abdominal se indica para obtener líquido ascítico para su análisis. También puede emplearse para evacuar ascitis a tensión que causa dificultad respiratoria o dolor, o como tratamiento de la ascitis crónica. Las contraindicaciones absolutas para la paracentesis incluyen Las contraindicaciones relativas son escasa cooperación del
paciente, cicatriz quirúrgica en la zona de punción, masas intraabdominales de gran tamaño e hipertensión portal grave con circulación colateral abdominal. Antes del procedimiento, se realizan un hemograma completo, recuento de plaquetas y estudios de coagulación. Después de vaciar la vejiga, el paciente se sienta en la cama con la cabeza
elevada de 45 a 90°.

En pacientes con ascitis evidente y marcada, se localiza un punto en la línea media entre el ombligo y el pubis, y se limpia con una solución antiséptica y alcohol. Otros dos sitios posibles para la paracentesis se encuentran a unos 3-5 cm superior y medial a la espina ilíaca anterosuperior a ambos lados. En pacientes con ascitis moderada, es correcto
determinar la localización precisa del líquido ascítico mediante ecografía. Colocar al paciente en decúbito lateral con el sitio de inserción planificado hacia abajo también promueve la flotación y la migración de las asas intestinales llenas de aire hacia arriba y lejos del punto de entrada. Con una técnica estéril, se anestesia el área hasta el peritoneo
con lidocaína al 1%. Para la paracentesis diagnóstica, se introduce una aguja de calibre 18 a 22 (1,5 o 3,5 pulgadas) unida a una jeringa de 30 a 50 mL a través del peritoneo (en general, se percibe un resalto). Se aspira con suavidad el líquido y se lo envía para recuento de células, determinación del contenido de proteínas o amilasa, citología o
cultivo, según sea necesario. En la paracentesis terapéutica (gran volumen), se introduce una cáncula 18-14 G unida a un sistema de aspiración al vacío para recoger hasta 8 L de líquido ascítico. Durante la paracentesis de grandes volúmenes, se recomienda la infusión simultánea de albúmina intravenosa para ayudar a evitar un desplazamiento
significativo de la volemia e hipotensión posterior al procedimiento. La hemorragia es la complicación más común de la paracentesis.

En ocasiones, en la ascitis a tensión se observa goteo prolongado de líquido ascítico a través del sitio de punción de la aguja. Explain the procedure to the patient and obtain written informed consent. Ask the patient to empty the bladder by voiding, or catheterize the patient. Place the patient in bed with the head elevated 45 to 90°.

In patients with obvious and a large amount of ascites, locate an insertion site at the midline between the umbilicus and the pubic bone, about 2 cm below the umbilicus. Locate an alternative site in the left lower quadrant, eg, about 3 to 5 cm superior and medial to the anterior superior iliac spine.
If choosing the left lower quadrant site, roll the patient partially onto the left side to allow the fluid to pool in the area.
The insertion site should be lateral enough to avoid the rectus sheath, which contains the inferior epigastric artery.
Alternatively, place the patient in a lateral decubitus position.
In this position, the air-filled bowel loops float up, migrating away from the point of entry, which should be down in the fluid-filled region. The left lateral decubitus position with needle insertion in the left lower quadrant is preferred by some physicians because the cecum may be distended with gas in the right lower quadrant. The right lateral
decubitus position can be used if needed. To choose a needle insertion site, carefully percuss, because dullness to percussion confirms the presence of fluid. If needed, use ultrasound to identify a site, confirming the presence of ascitic fluid and the absence of overlying bowel. In selecting an insertion site, avoid surgical scars and visible veins. If
available, mark the insertion site with a skin marking pen. Prepare the area with a skin cleansing agent, such as chlorhexidine or povidone iodine, and apply a sterile drape while wearing sterile gloves. Using a 25-gauge needle, place a wheal of local anesthetic over the insertion point. Switch to a larger (20- or 22-gauge) needle and inject anesthetic
progressively deeper until reaching the peritoneum, which should also be infiltrated because it is sensitive. When the needle is advanced, maintain constant negative pressure to ensure lidocaine is not injected into a blood vessel. For diagnostic paracentesis, select an 18- to 22-gauge (1.5-inch or 3.5-inch as needed) needle. For therapeutic
paracentesis, select an 18- to 14-gauge (1.5-inch or 3.5-inch as needed) needle or a Caldwell needle (15-gauge, 3.25-inch). Smaller-gauge needles lessen the risk of complications, such as ascitic fluid leakage, but take longer to complete therapeutic paracentesis. Insert the needle perpendicular to the skin at the marked site. Alternatively, insert the
needle using the Z-track method, which can be done in several ways. One option: Pull the skin, insert the needle perpendicularly, and maintain this skin traction until the needle enters the peritoneal cavity. Another option: Puncture just the skin, and pull it down, then advance into the peritoneal cavity. A third option: Insert the needle at an angle
(usually 45°) to the skin and advance it. The Z-track method is preferred because it allows the intra-abdominal pressure to help seal the tract after removing the needle and decreases the risk of peritoneal fluid leak. Insert the needle slowly to help avoid puncturing the bowel and use intermittent suction to avoid entering into a blood vessel. Avoid
continuous suction because this can cause tissue (eg, bowel, omentum) to occlude the needle tip. Insert the needle through the peritoneum (generally accompanied by a popping sensation) and gently aspirate fluid. For diagnostic paracentesis, withdraw enough fluid (eg, 30 to 50 mL) into the syringe and place the fluid in appropriate tubes and bottles
for testing, including blood culture bottles. For therapeutic paracentesis, if a Caldwell needle is used, advance the outer metal catheter over the needle, then remove the needle from inside the catheter. Attach the catheter to a collection bag or vacuum bottle using tubing. For therapeutic paracentesis, a large volume of fluid is removed. Removal of 5
to 6 L of fluid is generally well tolerated. In some patients, up to 8 L can be removed. Colloid replacement, such as concurrent infusion of IV albumin, is often recommended during large-volume paracentesis (eg, removal of > 5 L) to help avoid significant intravascular volume shift and post-procedure hypotension.
A 3-way stopcock can be used to control the flow of fluid when changing collection bottles or if a diagnostic sample is needed.

Remove the needle and apply pressure to the site. Apply a sterile adhesive bandage to the insertion site.