How to manage a paracentesis (percutaneous abdominal paracentesis) drain in a patient with a history of abdominal surgeries or procedures, who has broken stitches and an apparently stationary drain?

Management of Paracentesis Drain with Broken Stitches

If the drain has not moved and remains functional, secure it with a new purse-string suture and complete the drainage procedure, then remove the drain the same day—paracentesis drains should never be left in overnight. 1

Immediate Assessment

Verify Drain Position and Function

• Confirm the drain has not migrated by checking that it continues to drain ascitic fluid appropriately and that there is no change in the patient's abdominal examination 1
• Assess for any signs of bleeding (abdominal wall hematoma or hemoperitoneum), which occurs in approximately 1-5% of procedures 1, 2, 3
• Check for signs of infection at the insertion site, though infection from paracentesis is rare 1, 2

Key Clinical Principle

The drain should be removed the same day as insertion—leaving drains in overnight is explicitly not recommended. 1 The guideline states clearly: "In the author's opinion, the drain should not be left in overnight." 1

Management Algorithm

If Drain is Still Functional and Properly Positioned

1. Re-secure the drain immediately:

   • Place a new purse-string suture around the drain insertion site under sterile conditions 1
   • This prevents further ascitic fluid leakage and stabilizes the catheter 1

2. Complete the drainage procedure:

   • All ascitic fluid should be drained to dryness in a single session over 1-4 hours 1
   • Assist drainage by gentle mobilization of the cannula or turning the patient on their side if necessary 1

3. Remove the drain once drainage is complete:

   • Do not leave the drain in place overnight regardless of suture status 1
   • After removal, have the patient lie on the opposite side from the puncture site for 2 hours to minimize leakage risk 1, 4

If There is Concern About Drain Migration

• Use ultrasound to verify drain position if there is any clinical suspicion of displacement, as ultrasound guidance reduces complications and improves procedural success 5
• If the drain has migrated or is non-functional, remove it immediately and consider re-insertion at a new site if further drainage is needed 1

Post-Procedure Monitoring

Immediate Surveillance (First Hour)

• Monitor vital signs every 15 minutes for the first hour after drain removal 4
• Observe for 2-4 hours total post-procedure 4

Watch for Hemorrhagic Complications

• Abdominal wall hematomas (most common at 52% of hemorrhagic complications) and hemoperitoneum (41%) are the primary bleeding risks 3
• Hemorrhagic complications requiring intervention occur in approximately 1.6% of therapeutic paracentesis procedures 2
• If significant bleeding occurs, interventional radiology with transcatheter coiling/embolization is superior to surgical intervention, with lower 30-day mortality 3

Manage Ascitic Fluid Leakage

• Ascitic fluid leakage at the puncture site occurs in approximately 5% of cases 2
• If leakage persists, ensure the patient lies on the opposite side for 2 hours 1, 4
• A properly placed purse-string suture minimizes this risk 1

Critical Safety Points

Coagulopathy is NOT a Contraindication

• Bleeding complications occur in less than 1 in 1,000 procedures, and there is no data-supported cutoff for INR or platelet count that contraindicates paracentesis 1, 6
• Prophylactic transfusion of fresh frozen plasma or platelets is not recommended 1

Avoid Vascular Injury

• The broken suture situation does not change the underlying vascular anatomy risk 6, 7
• Inferior and superior epigastric arteries run in the rectus sheath and must be avoided 6
• If repositioning is needed, use color Doppler ultrasound to identify and avoid abdominal wall vessels 5

Common Pitfalls to Avoid

• Never leave the drain in overnight even if sutures have broken—this is explicitly contraindicated by guidelines 1
• Do not remove the drain and continue antibiotics alone for persistent collections without clinical indication 8
• Do not assume coagulopathy requires drain removal or delay in completing the procedure 1, 6