Atlas of Procedures in Neonatology, 4th Edition

Miscellaneous Sampling

25

Abdominal Paracentesis

  1. Alfred Chahine
  2. Indications
  3. Therapeutic
  4. Massive ascites with cardiorespiratory compromise
  5. Diagnostic
  6. Necrotizing enterocolitis with suspicion of gangrene or perforation, looking for fecal matter or bacteria and white blood cells on a smear (1,2 and 3)
  7. Chylous ascites: testing for lymphocytes on cell count of the fluid (4)
  8. Urinary ascites: test for creatinine content (5,6)
  9. Meconium peritonitis: gross appearance of ascites (7)
  10. Biliary ascites: test for bilirubin level.
  11. Congenital infections—cytomegalovirus (CMV), tuberculosis, toxoplasmosis, syphilis: test for inclusion bodies, treponemes (4,8)
  12. Inborn errors of metabolism—sialic acid storage disorders: test for vacuolated lymphocytes and free sialic acid (9,10)
  13. Iatrogenic ascites from extravasation of fluid from central venous catheters: test for glucose content
  14. Contraindications

Coagulopathy is a relative contraindication; the procedure may be performed with concomitant treatment of thrombocytopenia or coagulopathy.

  1. Equipment
  2. 24- or 25-gauge catheter over a needle (e.g., Angiocath)
  3. 5- or 10-mL syringe
  4. Skin topical disinfectant
  5. Sterile towels
  6. Tubes for culture, Gram stain, and cell count
  7. Tuberculin syringe
  8. Lidocaine (1%)
  9. Technique (See Procedures DVD for Video)
  10. A soft support (“bump”) is placed under the neonate's left flank, to allow as much of the fluid to drain into and allow the intestines to float away from the right lower quadrant (Fig. 25.1).
  11. The right lower quadrant is prepared with the disinfecting solution.
  12. A point between the umbilicus and the anterior superior iliac spine one third of the way from the anterior superior iliac spine is chosen.
  13. The skin, muscles, and peritoneum are infiltrated with the local anesthetic using the tuberculin syringe.
  14. The 10-mL syringe is connected to the 24-gauge catheter and needle.
  15. The catheter is pointed toward the back and held at a 45-degree angle (Fig. 25.2).
  16. The catheter and needle are slowly pushed through the skin, muscles, and peritoneal surface while applying gentle suction on the syringe plunger.
  17. When peritoneal fluid is aspirated, the catheter is advanced and the needle withdrawn.
  18. The syringe is connected to the catheter and suction applied to aspirate as much fluid as possible.
  19. If fluid is not free-flowing, the catheter might be inside the lumen of a piece of intestine or in the retroperitoneum. The catheter is withdrawn and the maneuver repeated with the catheter at a slightly different angle.
  20. When the fluid stops flowing, the catheter is withdrawn.
  21. The fluid is distributed into the various tubes and cups for the appropriate studies.
  22. A bandage is applied.
  23. Complications
  24. Bleeding from the liver or intra-abdominal vessels; may be severe enough to require a laparotomy
  25. Intestinal perforation; usually inconsequential because the catheter and needle are of small diameter.

P.139

 

FIG. 25.1. Appropriate position and disinfection of abdomen prior to performing paracentesis in preterm neonate.

 

FIG. 25.2. Entry site and direction of needle for abdominal paracentesis in preterm neonate.

References

  1. Ricketts RR.The role of paracentesis in the management of infants with necrotizing enterocolitis. Am Surg. 1986;52(2):61–65.
  2. Ricketts RR, Jerles ML.Neonatal necrotizing enterocolitis: experience with 100 consecutive surgical patients. World J Surg.1990;14:600–605.
  3. Kosloske AM.Indications for operation in necrotizing enterocolitis revisited. J Pediatr Surg. 1994;29(5):663–666.
  4. Lee YY, Soong WJ, Lee YS, Hwang B.Total parenteral nutrition as a primary therapeutic modality for congenital chylous ascites: report of one case. Acta Paediatr Taiwan. 2002;43(4):214–216.
  5. Oei J, Garvey PA, Rosenberg AR.The diagnosis and management of neonatal urinary ascites. J Paediatr Child Health.2001;37(5):513–515.
  6. Ku JH, Kim ME, Jeon YS, et al. Urinary ascites and anuria caused by bilateral fungal balls in a premature infant. Arch Dis Child Fetal Neonatal Ed.2004;89(1):F92–F93.
  7. Shyu MK, Shih JC, Lee CN, et al. Correlation of prenatal ultrasound and postnatal outcome in meconium peritonitis. Fetal Diagn Ther.2003;18(4):255–261.
  8. Nicol KK, Geisinger KR.Congenital toxoplasmosis: diagnosis by exfoliative cytology. Diagn Cytopathol. 1998;18:357–361.
  9. Sergi C, Beedgen B, Kopiz J, et al. Refractory congenital ascites as a manifestation of neonatal sialidosis: clinical, biochemical and morphological studies in a newborn Syrian male infant. Am J Perinatol.1999;16:133–141.
  10. Lemyre E, Russo P, Melancon SB, et al. Clinical spectrum of infantile free sialic acid storage disease. Am J Med Genet.1999;82:385–391.