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
RESULTS
Literature search
A total of 794 references were pooled and screened from literature searches conducted by a certified medical librarian in October 2015 (604 citations) and updated in November 2017 (118 citations), and working group members’ personal bibliographies and searches (72 citations; Appendix 3, Figure 2). Final selection included 91 articles that were abstracted into a data table and incorporated into the draft recommendations.
RECOMMENDATIONS
Four domains (terminology, clinical outcomes, technique, and training) with 13 draft recommendations were generated based on the literature review by the paracentesis working group. After two rounds of panel voting, one recommendation did not achieve consensus based on the RAND rules, and 12 statements received final approval. The degree of consensus based on the median score and dispersion of voting around the median are shown in Appendix 5. All 12 statements achieved consensus as strong recommendations. The strength of each recommendation and degree of consensus are summarized in Table 3.
Terminology
Abdominal paracentesis is a procedure in which fluid is aspirated from the intraperitoneal space by percutaneous insertion of a needle with or without a catheter through the abdominal wall. Throughout this document, the term “paracentesis” refers to “abdominal paracentesis.”
In this document, ultrasound-guided paracentesis refers to the use of static ultrasound guidance to mark a needle insertion site immediately prior to performing the procedure. Real-time (dynamic) ultrasound guidance refers to tracking of the needle tip with ultrasound as it traverses the abdominal wall to enter the peritoneal cavity. Landmark-based paracentesis refers to paracentesis based on physical examination alone.
RECOMMENDATIONS
Clinical outcomes
1. We recommend that ultrasound guidance should be used for paracentesis to reduce the risk of serious complications, the most common being bleeding.
Rationale. The occurrence of both minor and serious life-threatening complications from paracentesis has been well described.5-10,31,32 A recent retrospective study that evaluated 515 landmark-guided paracenteses noted that the most common minor complication was persistent ascites leakage (5%) and that the most common serious complication was postprocedural bleeding (1%).8 Studies have shown that abdominal wall hematoma and hemoperitoneum are common hemorrhagic complications of paracentesis, although inferior epigastric artery pseudoaneurysm has also been described.9,33,34
Current literature suggests that ultrasound-guided paracentesis is a safe procedure, even with reduced platelet counts or elevated international normalized ratio.35-42 Most comparative studies have shown that ultrasound guidance reduces the risk of bleeding complications compared with the use of landmarks alone,7,31,32,43-45 although a few studies did not find a significant difference between techniques.20,36,46 One large retrospective observational study that analyzed the administrative data of 69,859 paracenteses from more than 600 hospitals demonstrated that ultrasound guidance reduced the odds of bleeding complications by 68% (OR, 0.32; 95% CI, 0.25–0.41). Bleeding complication rates with and without the use of ultrasound guidance were 0.27% (CI 0.26-0.29) versus 1.25% (CI 1.21-1.29; P < .0001), respectively. More importantly, in this study, paracentesis complicated by bleeding was associated with a higher in-hospital mortality rate
