When I was a resident, it was impossible to find paracentesis kits in our department. What we did have was a lot of cirrhotic patients who would come by twice a month for a sandwich and a tap (and often a little methadone). Vacuum bottles were never available, so it wasn’t uncommon for us to drain liters of ascites into plastic urinals or bedpans. There was nowhere else to put all that fluid.

In our crowded department more than one resident had the sad experience of stepping directly into a tub of warm, hepatitis C-positive ascites, completely saturating their shoes and socks. After pouring a bottle of hydrogen peroxide over each polluted clog, the rest of the shift would be spent working in a makeshift “barrier device,” hospital socks covered with plastic lab bags tied around our feet (crammed back into our moist, foaming shoes). It was a terrible system.

If you have a dedicated paracentesis kit and you need to do a therapeutic (large volume) tap, then use the kit. If you don’t, you can put together a good system using a standard Foley catheter kit, IV tubing, a spinal needle, and some suture removal scissors.

The Basics: There are many steps – I’m just focusing on creating a collection system, so be sure to peruse your favorite procedure text before getting started (especially if it’s been a while).Always make sure your patient has emptied his or her bladder, made their phone call, and isn’t near a meal tray left tantalizingly out of reach. Otherwise you will return to find your patient walking down the hall with their paracentesis tubing skittering across the floor, spewing an amber geyser of ascites onto the linoleum just after it’s been waxed for the fifth time that day.

Informed consent, a coagulation profile and platelet count, ultrasound guidance, local anesthesia, and a sterile prep of the puncture site are non-negotiable steps. I prefer to have the patient upright, and often a chair works better than a sloping stretcher. Different sources recommend a variety of locations for the tap site, though lately I have become a fan of the linea alba, 2 or 3 centimeters below the umbilicus: there are relatively few vessels to lacerate in this area, and needles or catheters protruding from the lower quadrants always seem to get bumped by the patient’s incredibly tight underwear (that they refuse to remove), piles of blankets, phones, meal trays, or visitors.

Collection System: Take a standard Foley kit and clamp off the hose near to the collection bag, and then cut a hole in the collection tubing using sterile scissors (disposable ones from a suture removal kit are fine). Next, cut some IV tubing with the same sterile scissors and tuck one end into the hole in the Foley collection tubing. Then hang the Foley bag below the patient or even place it on the floor. Connect other end of the IV tubing (with the screw hub) to your puncture needle. The IV tubing should be long enough to prevent small movements from yanking it out of the patient or the Foley tubing, but shouldn’t have excessive slack. Three feet (~90 cm) is a good place to start. A three-way stopcock is a nice addition, but not essential. (Figure 1).

Needle or Angiocatheter? Since we’re talking about a “no kit” situation with an anticipated high volume paracentesis, you’re left with the option of using an angiocathether (from an IV or central line kit) or a simple needle to puncture the peritoneal cavity. Both can work, but where I work most IV angiocatheters tend to be too short and kink or collapse too easily. I usually use a 20-gauge spinal needle with the plastic needle guard cut short to match the abdominal wall thickness from your preliminary ultrasound. By leaving the needle guard on, the patient can’t ram the needle through the bowel and into the aorta and spinal cord should he or she decide to do push-ups.

Insert the spinal needle using sterile technique after anesthetizing the patient. Put some caudal tension on the skin before inserting your needle to help the tract seal up once you remove the needle. If you leave the stylet in the needle, remove it frequently as you advance a few millimeters at a time. Once you get flow of ascites, connect your IV tubing.

You’ll need to support the needle with a few gauze rolls taped to the patient’s abdomen. (Figure 2). Some people like to add a three-way stopcock to the mix.

What Next?: Once ascites starts collecting in the Foley bag, all you have to do is watch. This system is sterile, and it allows you to precisely measure the volume of fluid you are removing – my personal cutoff is 2.5 liters, though some people will remove much more. If you need specimens for the lab, use the drainage port in the Foley bag to collect sterile samples. Once fluid stops draining, resist the temptation to wobble the needle around in the patient’s abdomen in the hopes of getting a little more. Remove the needle carefully to avoid getting stuck.

Avoiding Death and Janitorial Complaints: Remember to keep the Foley bag LOWER than the patient to avoid sucking air into the patient’s peritoneum, especially at the end of the procedure. When discarding ascites from Foley bag, let it drain out into your disposal system cautiously without a lot of splashing, and wear eye and mouth protection. Since the patient is usually still numb from the initial local anesthesia, I put a figure-of-8 stitch around the perforation site to keep any residual fluid from oozing out (a common patient complaint). I prefer an absorbable suture to spare the patient a return trip. Cover the site with an occlusive dressing.

There are tales of patients going into shock or having spontaneous peritoneal bleeds after large volume paracentesis, and while these complications are reportedly rare it is a good idea to observe the patient in the department for an hour after the procedure has been completed. Sandwiches and promises of cab fare are your greatest weapons here, should you choose to use them.

Have a nifty idea you’d like to see on Tricks of the Trade? E-mail it to me at fisherwhit@gmailwww.acepnews.com, and I promise to give you credit if I use it.

Dr. Fisher practices Emergency Medicine in New England and New York.