Procedures

Paracentesis (diagnostic and large-volume)

Reviewed Nov 2026·3 references
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Site, safety in coagulopathy, essential tests, SAAG, SBP diagnosis and albumin after large-volume paracentesis.

Definition
Diagnostic paracentesis for every patient with cirrhosis and ascites admitted to hospital or deteriorating (SBP screening). Large-volume paracentesis (LVP) for tense or refractory ascites. Routine FFP or platelets are not recommended before paracentesis.

At the bedside

  1. 1

    Indication

    New ascites, any hospital admission with ascites, fever, encephalopathy, AKI or GI bleed in cirrhosis.

  2. 2

    Site

    Left lower quadrant, about 2 finger-breadths medial and cephalad to the anterior superior iliac spine; ultrasound guidance; avoid inferior epigastric vessels and scars.

  3. 3

    Coagulopathy

    Do not routinely give FFP or platelets; avoid in DIC or clinically evident fibrinolysis.

  4. 4

    Tests

    Cell count and differential, albumin (SAAG), total protein, culture in blood culture bottles at the bedside (10 mL each); amylase, cytology, ADA as indicated.

  5. 5

    Interpret

    SBP: neutrophils ≥ 250/µL. SAAG ≥ 1.1 g/dL = portal hypertension; total protein < 1.5 g/dL = higher SBP risk.

  6. 6

    LVP

    Remove ascites to dryness if tolerated; give 20% albumin 6-8 g/L removed when > 5 L.

Local anaesthetic

Lidocaine (lignocaine)

Infiltration
Dose
1-2% lidocaine; stay under 4.5 mg/kg plain
Worked example
70 kg: max ~300 mg plain = 30 mL of 1% (10 mg/mL) or 15 mL of 2%.

After LVP > 5 L

Human albumin 20%

IV
Dose
6-8 g per litre removed
Worked example
8 L removed: 48-64 g albumin = 240-320 mL of 20% albumin (about 2.5-3 bottles of 100 mL).
Red flag · call your senior now
Abdominal pain, falling haemoglobin or hypotension after paracentesis: suspect abdominal wall haematoma or haemoperitoneum (inferior epigastric injury).
Pitfall
Delaying diagnostic paracentesis for INR correction.
Pitfall
Sending ascitic fluid in a sterile container only - culture yield is higher when inoculated into blood culture bottles at the bedside.
Pearl
Polymicrobial growth with very high protein or low glucose suggests secondary (surgical) peritonitis - image for perforation.

References

  1. 1

    Biggins SW, Angeli P, Garcia-Tsao G, et al. Diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: 2021 practice guidance by the AASLD. Hepatology 2021;74:1014-48.

  2. 2

    Patel IJ, Rahim S, Davidson JC, et al. Society of Interventional Radiology consensus guidelines for the periprocedural management of thrombotic and bleeding risk in patients undergoing percutaneous image-guided interventions - part II: recommendations. J Vasc Interv Radiol 2019;30:1168-84.

  3. 3

    Neal JM, Barrington MJ, Fettiplace MR, et al. The third American Society of Regional Anesthesia and Pain Medicine practice advisory on local anesthetic systemic toxicity: executive summary 2017. Reg Anesth Pain Med 2018;43:113-23.

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