Trick of the Trade: Large volume paracentesis technique using gravity

Recall the last time you were sitting in a room doing a large-volume, therapeutic paracentesis in the ED. Were you stressing out because your other patients were still being actively managed? Large-volume paracentesis is a common and important part of our practice, but often requires your dedicated time at the bedside. Additionally, what do you do if you do not have the fancy paracentesis kit or vacuum collection bottles?

Trick of the Trade: A “poor man’s” paracentesis technique using gravity

I was introduced to the concept of paracentesis and thoracentesis drainage to gravity when I worked in a rural Kenyan ED during residency. All I had were straight needles and angiocatheters. There were no paracentesis kits or vacuum collection bottles.

Good for:

• Massive ascites
• When you don’t have 45-60 minutes to sit in one place

Bad for:

• Small fluid pockets
• Thick abdominal wall tissue/muscle

Step 1: Assemble Supplies

• Large gauge angiocath — 16g or larger (I use 14g)
• IV tubing (short connector) – Needs both the “male” end for the angiocatheter and the “female” end for the foley
• 3-way stop-cock
• Urinary foley catheter (16 or 18F)
• Urine foley drainage bag
• Sterile gloves
• Betadine or chlorhexidine
• Plastic tape
• Scissors

Step 2: Cut foley catheter (which is attached to the bag tubing) off at the hub

Step 3: Snugly insert the “female” end of the IV tubing/stopcock into the new end of the foley

Step 4: Perform a paracentesis by usual technique, using an angiocatheter

Step 5: Connect the angiocatheter to the IV tubing and foley bag collection system

• Use generous amounts of tape. Both the angiocatheter and the foley drainage tubing need support to prevent its weight from kinking or inadvertently pulling out the angiocatheter.

Step 6: Perform frequent rechecks

• Check the drainage process every 10-15 minutes to see if the angiocatheter needs to be repositioned or if the bag needs to be emptied.
• Using the urine collection bag means you can just empty the bag into a urine container or basin.

Discussion:

The beauty and curse of this paracentesis technique is the use of a venous angiocatheter. The angiocatheter has fundamental weaknesses when used in this manner– it is relatively short (doesn’t work when abdominal wall is thick), made of pliant plastic (kinks easily), and has only a single lumen instead of being fenestrated like the usual paracentesis catheters (can get obstructed by bowel/tissue). Yet, even in a developed country, I do it routinely for large volume paracentesis because of the significant advantages. When it works, not only do you look like MacGyver, but it frees up valuable time and, frankly, seems to be more comfortable for patients.

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