Recommendations on the Use of Ultrasound Guidance for Adult Abdominal Paracentesis: A Position Statement of the Society of Hospital Medicine
1. We recommend that ultrasound guidance should be used for paracentesis to reduce the risk of serious complications, the most common being bleeding.
2. We recommend that ultrasound guidance should be used to avoid attempting paracentesis in patients with an insufficient volume of intraperitoneal free fluid to drain. 3. We recommend that ultrasound guidance should be used with paracentesis to improve the success rates of the overall procedure.
4. We recommend that ultrasound should be used to assess the volume and location of intraperitoneal free fluid to guide clinical decision making of where paracentesis can be safely performed.
5. We recommend that ultrasound should be used to identify a needle insertion site based on size of the fluid collection, thickness of the abdominal wall, and proximity to abdominal organs.
6. We recommend that the needle insertion site should be evaluated using color flow Doppler ultrasound to identify and avoid abdominal wall blood vessels along the anticipated needle trajectory.
7. We recommend that a needle insertion site should be evaluated in multiple planes to ensure clearance from underlying abdominal organs and detect any abdominal wall blood vessels along the anticipated needle trajectory.
8. We recommend that a needle insertion site should be marked with ultrasound immediately before performing the procedure, and the patient should remain in the same position between marking the site and performing the procedure.
9. We recommend that using real-time ultrasound guidance for paracentesis should be considered when the fluid collection is small or difficult to access.
10. We recommend that dedicated training sessions, including didactics, supervised practice on patients, and simulation-based practice, should be used to teach novices how to perform ultrasound-guided paracentesis.
11. We recommend that simulation-based practice should be used, when available, to facilitate acquisition of the required knowledge and skills to perform ultrasound-guided paracentesis. 12. We recommend that competence in performing ultrasound-guided paracentesis should be demonstrated prior to independently performing the procedure on patients.
© 2019 Society of Hospital Medicine
Abdominal paracentesis is a common and increasingly performed procedure in the United States. According to Medicare Physician Supplier Procedure Summary Master Files, an estimated 150,000 paracenteses were performed on Medicare fee-for-service beneficiaries in 2008 alone; such a number represents more than a two-fold increase from the same service population in 1993.1 This increasing trend was again noted by the Nationwide Inpatient Sample data, which identified a 10% increase in hospitalized patients with a diagnosis of cirrhosis receiving paracentesis from 2004 (50%) to 2012 (61%; P < .0001).2
Although these data demonstrate that paracentesis is being performed frequently, paracentesis may be underutilized in hospitalized cirrhotics with ascites. In addition, in-hospital mortality of cirrhotics with ascites is higher among those who do not undergo paracentesis than among those who do (9% vs 6%; P = .03).3,4
While complications associated with paracentesis are rare, serious complications, including death, have been documented.5-10 The most common serious complication of paracentesis is bleeding, although puncture of the bowel and other abdominal organs has also been observed. Over the past few decades, ultrasound has been increasingly used with paracentesis due to the ability of ultrasound to improve detection of ascites11,12 and to avoid blood vessels10,13-15 and bowels.16
Three-quarters of all paracenteses are currently performed by interventional radiologists.1 However, paracenteses are often required off-hours,17 when interventional radiologists are less readily available. Weekend admissions have less frequent performance of early paracentesis than weekday admissions, and delaying paracentesis may increase mortality.3,18 High proficiency in ultrasound-guided paracentesis is achievable by nonradiologists19-28 with equal or better patient outcomes after appropriate training.29
The purpose of this guideline is to review the literature and present evidence-based recommendations on the performance of ultrasound-guided paracentesis at the bedside by practicing hospitalists.
