Best Practices for Performing Paracentesis

Use ultrasound guidance for all paracentesis procedures to reduce bleeding complications by 68% and improve overall safety. 1

Pre-Procedure Preparation

Obtain informed consent from all patients before performing therapeutic or diagnostic paracentesis 1
Do not routinely check PT/INR or platelet counts before paracentesis - even with INR up to 8.7 or platelets as low as 19×10³/μL, routine correction is not recommended 1, 2
Do not prophylactically transfuse fresh frozen plasma or platelets unless there is clinically evident hyperfibrinolysis or disseminated intravascular coagulation 1

Absolute contraindications: clinically evident hyperfibrinolysis or disseminated intravascular coagulation 1
Relative contraindications: pregnancy, severe intestinal distension, and extensive abdominal surgery history - use ultrasound guidance in these cases 1

Prefer the left lower quadrant - this location has greater ascites depth and thinner abdominal wall compared to other sites 1
Insert the needle at least 8 cm from the midline and 5 cm above the symphysis pubis to avoid the inferior epigastric artery and minimize risk of bowel or vascular injury 1
Use the "Z-track" technique to ensure puncture sites on the skin and peritoneum don't directly overlie each other, reducing leakage risk 3, 2

Use ultrasound guidance for every paracentesis - this reduces bleeding complications by 68% and lowers overall adverse event rates 1
Evaluate the needle insertion site with color flow Doppler to identify and avoid abdominal wall blood vessels along the anticipated needle trajectory 4
Assess the site in multiple planes to ensure clearance from underlying organs and detect vessels 4
Mark the site immediately before the procedure and keep the patient in the same position between marking and needle insertion 4
Consider real-time ultrasound guidance (not just site marking) when fluid collections are small or difficult to access 4, 5
Use a linear transducer when possible - all procedures using linear transducers in one study were successful, while failures occurred with curvilinear transducers 5

Drain all ascitic fluid to dryness in a single session over 1-4 hours - do not perform repeated low-volume paracentesis as this increases complication risk 1, 2
Remove fluid at approximately 2-9 liters per hour - historical concerns about rapid drainage causing circulatory collapse have been disproven 2
Assist drainage by gentle mobilization of the cannula or turning the patient onto their side if flow slows 1
Do not leave the drain in overnight 2

For volumes >5 liters: mandatory albumin replacement at 8 g per liter of ascites removed (e.g., 100 mL of 20% albumin per 3 liters removed) 1, 2
For volumes <5 liters: albumin replacement is not necessary unless the patient has acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury 1, 2
Infuse albumin after paracentesis is completed, not during the procedure 2
This prevents post-paracentesis circulatory dysfunction, reducing odds of renal impairment by 61%, hyponatremia by 42%, and mortality by 36% 2

Have the patient lie on the opposite side for 2 hours after the procedure if there is any leakage 1, 3
Apply a purse-string suture around the drainage site for persistent leakage - this is one of the most effective management methods 3

Watch for bleeding complications (0.2-2.7% incidence) - most occur within 6-24 hours but can appear up to 1 week post-procedure 1
Monitor for ascitic fluid leak (0-2.35% incidence), perforation (0.83%), and infection at the puncture site 1
Most bleeding can be managed with fluid resuscitation, transfusion, and correction of coagulation disorders 1
Consider transcatheter coil embolization or laparoscopy if hemodynamic instability persists despite medical treatment 1

Do not artificially slow drainage rate out of concern for hemodynamic instability - this outdated practice delays symptom relief without evidence of benefit 2
Do not withhold paracentesis due to coagulopathy - routine correction is not recommended and delays necessary treatment 1, 2
Do not perform repeated small-volume paracentesis - single large-volume drainage is faster, more effective, and has lower complication rates 1, 2
Do not skip ultrasound guidance even if you are experienced - operator experience alone does not eliminate the benefit of ultrasound in reducing complications 1, 4

Minimum of 10 supervised procedures is sufficient for trained nurses to achieve low complication rates 1
Use simulation-based practice when available to facilitate skill acquisition 4
Demonstrate competence before performing independently on patients 4