Pre‐procedure

ActionRationale

1. 1.Show
   Explain and discuss the procedure with the patient.
   To ensure that the patient is involved in the decision and understands the procedure, the agreed aim, the risks and benefits. Informed consent may then be obtained (Campbell [28], R5; Cope [47], R5; NMC [214], C).
2. 2.Show
   Ask the patient to empty their bladder prior to ultrasound (US) marking.
   If the bladder is full there is a chance of it being punctured when the trocar is introduced (McGibbon et al. [175], E). If the bladder is emptied post US marking it will alter the site of marking, making it inaccurate. E
3. 3.Show
   3 Weigh the patient before the procedure and measure the girth and record.
   To assess weight changes and fluid loss. E
4. 4.Show
   Ensure privacy.
   To maintain dignity (DH [58], C).
5. 5.Show
   Lie the patient supine in bed with the head raised 45–50 cm with a backrest.
   Normally the pressure in the peritoneal cavity is no greater than atmospheric pressure, but when fluid is present pressure becomes greater than atmospheric pressure. This position will aid gravity in the removal of fluid and the fluid will drain of its own accord until the pressure is equalized. E
6. 6.Show
   Using US, mark the area of greatest depth on the abdomen using a skin marker.
   To indicate the site for the drain in order to reduce the risk of perforating vital organs, specifically bowel, if under the site of insertion (Royal College of Obstetricians and Gynaecologists [256], C). A depth of >  3.5 cm is recommended. E
7. 7.Show
   Following the US marking and when it is safe to proceed, ensure that the patient has signed a consent form.
   Informed consent may then be obtained (Campbell [28], R5; Cope [47], E; NMC [214], C).

Procedure

1. 8.Show
   Wash hands.
   To minimize risk of contamination. E
2. 9.Show
   Perform the procedure using an aseptic technique. Always perform the procedure in hospital with a second, appropriately trained, person.
   To minimize risk of contamination. E

   To ensure patient safety at all times. E
3. 10.Show
   10 Bring equipment to the bedside on a cleaned trolley. Remove the sterile abdominal paracentesis pack from its outer wrapping and open it on the trolley.
   To minimize the risk of infection. E

   To facilitate access to the equipment. E

   To create a clean working area. E
4. 11.Show
   Put on a disposable plastic apron and sterile gloves; open inner pack, arranging the contents as required.
   To protect the professional and patient from the risks of cross‐infection. E
5. 12.Show
   Clean the skin thoroughly at the marked site for the paracentesis with an antiseptic solution, for example chlorhexidine 0.5% and alcohol solution, and allow to dry. Drape with sterile towels.
   To reduce the risk of local and/or systemic infection. The peritoneal cavity is normally sterile (Fraise and Bradley [83], E; Lee et al. [139], R5). To prevent contamination (Loveday et al. [153], C).
6. 13.Show
   Draw up 10 mL of 1 or 2% lidocaine into a 10 mL syringe and attach a 25 G needle. Administer local anaesthetic to raise a small lidocaine skin wheal around the skin entry site. Switch to the longer 20 G needle, and administer 4–5 mL of lidocaine along the catheter insertion tract. Make sure to anaesthetize all the way down to the peritoneum. Alternate injection and intermittent aspiration down the tract until ascitic fluid is noticed in the syringe.
   To minimize pain during the procedure (Runyon [259], E).

   To have medications prepared for use. E

   To ensure that the catheter insertion tract is anaesthetized E.

   To note the length of the tract prior to reaching the peritoneum to assist with anticipated length of catheter to be inserted to reach the fluid within the peritoneum. E
7. 14.Show
   Once the anaesthetic has taken effect, make an incision with the scalpel (approximately 5 mm length by 3 mm depth) into the skin of the abdomen (the position may have been marked previously in radiology following US). The incision should be long enough to aid entry of the trocar.
   Allows for easier passage of the catheter. E

   To minimize pain during the procedure and thus maximize patient comfort and facilitate co‐operation (Runyon [259], E).
8. 15.Show
   Depending on the type of catheter used, the trocar and cannula are inserted perpendicular to the skin via the incision either together or in succession. Slowly insert in increments of 5 mm. Upon entry into the peritoneal cavity, loss of resistance is felt and flashback of ascetic fluid is present.
   To ensure correct insertion of the trocar and cannula. E

   Slow insertion reduces the risk of vascular entry or puncture of the small bowel. E
9. 16.Show
   Once there is flashback of ascitic fluid, insert the trocar and cannula further. The depth of insertion is the depth of subcutaneous tissue plus a third of the depth of fluid as dictated by US measurements.
   To ensure the cannula is in the correct position. E
10. 17.Show
    Attach a sterile syringe to the end of the catheter and withdraw 3–10 mL of free‐flowing ascites and then advance the cannula.
    If the fluid return in the syringe is bubbling this may signal bowel perforation.

    To ascertain there is no bowel perforation and ensure the cannula is in free‐flowing fluid. E
11. 18.Show
    The trocar is removed and disposed of in a sharps container.
    To reduce the risk of accidental needlestick injury (NHS Employers [200], C).
12. 19.Show
    Attach the closed drainage system to the cannula using a connector if appropriate. Apply an appropriate dry dressing to ensure the drain exit site is protected and the drain is taped firmly in position.
    A sterile container with a non‐return valve is necessary to maintain sterility. To reduce local and/or systemic infection. E
13. 20.Show
    Collect ascitic fluid from the sterile drainage bag prior to it being hung by the bedside (20–100 mL as instructed by the patient's clinical team) and send for cytology, biochemistry (albumin, lactate dehydrogenase [LDH], protein) and microbiology. This can be taken directly from the tap on the drainage bag as this is sterile immediately post procedure.
    If necessary, in order to diagnose the cause of ascites and for continued monitoring of fluid (Fentiman [76], E; Hosttetter et al. [112], E). Enables the clinician to ascertain if the ascites is exudate or transudate.
14. 21.Show
    If the cannula is to remain in position, ensure that it is secured using a sterile dry dressing fixed in position by adhesive tape (e.g. Mefix) covering the entire dressing.
    To prevent the cannula becoming dislodged and to prevent local trauma to the patient. E

Post‐procedure

1. 22.Show
   Dispose of the equipment and remove gloves and apron.
   To reduce the risk of environmental contamination (Fraise and Bradley [83], E).
2. 23.Show
   Monitor the patient's blood pressure, pulse and respirations after each litre of fluid is drained.
   To observe for signs of shock and/or infection. E
3. 24.Show
   Observe the rate and nature of the drainage. Reduce the flow of fluid using the clamp available in the tube if the patient complains of light‐headedness.
   To ensure safe and unobstructed drainage. E
4. 25.Show
   Monitor and record the drain output.
   To ensure accurate recording of the amount of ascitic fluid drained. E
5. 26.Show
   If draining  <  200 mL per hour, encourage the patient to walk about to move ascitic fluid within the abdominal cavity.
   To encourage fluid drainage (Runyon [259], E).
6. 27.Show
   When there is no further output remove the drain and apply a dry dressing.
   To reduce the risk of infection (Fraise and Bradley [83], E; Lee et al. [139], R5).
7. 28.Show
   Weigh the patient after the catheter is removed and record.
   To assess weight changes and fluid loss. E
8. 29.Show
   Measure the patient's girth around the umbilicus after the procedure and record.
   This provides an indication of fluid shift and how much fluid has reaccumulated. E