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
CONCLUSIONS
The use of ultrasound guidance for paracentesis has been associated with higher success rates and lower complication rates. Ultrasound is superior to physical examination in assessing the presence and volume of ascites, and determining the optimal needle insertion site to avoid inadvertent injury to abdominal wall blood vessels. Hospitalists can attain competence in ultrasound-guided paracentesis through the use of various training methods, including lectures, simulation-based practice, and hands-on training. Ongoing use and training over time is necessary to maintain competence.
Acknowledgments
The authors thank all the members of the Society of Hospital Medicine Point-of-care Ultrasound Task Force and the Education Committee members for their time and dedication to develop these guidelines.
SHM Point-of-care Ultrasound Task Force: CHAIRS: Nilam Soni, Ricardo Franco Sadud, Jeff Bates. WORKING GROUPS: Thoracentesis Working Group: Ria Dancel (chair), Daniel Schnobrich, Nitin Puri. Vascular Access Working Group: Ricardo Franco (chair), Benji Matthews, Saaid Abdel-Ghani, Sophia Rodgers, Martin Perez, Daniel Schnobrich. Paracentesis Working Group: Joel Cho (chair), Benji Mathews, Kreegan Reierson, Anjali Bhagra, Trevor P. Jensen. Lumbar Puncture Working Group: Nilam J. Soni (chair), Ricardo Franco, Gerard Salame, Josh Lenchus, Venkat Kalidindi, Ketino Kobaidze. Credentialing Working Group: Brian P Lucas (chair), David Tierney, Trevor P. Jensen PEER REVIEWERS: Robert Arntfield, Michael Blaivas, Richard Hoppmann, Paul Mayo, Vicki Noble, Aliaksei Pustavoitau, Kirk Spencer, Vivek Tayal. METHODOLOGIST: Mahmoud El Barbary. LIBRARIAN: Loretta Grikis. SOCIETY OF HOSPITAL MEDICINE EDUCATION COMMITTEE: Daniel Brotman (past chair), Satyen Nichani (current chair), Susan Hunt. SOCIETY OF HOSPITAL MEDICINE STAFF: Nick Marzano.
Collaborators of the Society of Hospital Medicine Point-of-care Ultrasound Task Force
Saaid Abdel-Ghani, Robert Arntfield, Jeffrey Bates, Michael Blaivas, Dan Brotman, Carolina Candotti, Richard Hoppmann, Susan Hunt, Venkat Kalidindi, Ketino Kobaidze, Josh Lenchus, Paul Mayo, Satyen Nichani, Vicki Noble, Martin Perez, Nitin Puri, Aliaksei Pustavoitau, Sophia Rodgers, Gerard Salame, Daniel Schnobrich, Kirk Spencer, Vivek Tayal, David M. Tierney
Disclaimer
The contents of this publication do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.
All 5 appendices are viewable online at https://www.journalofhospitalmedicine.com.
