A 65 year old male with stage IV liver cancer presents with vomiting, increased jaundice, and confusion. Vitals are normal, but on physical exam you notice a distended abdomen. You order a sepsis work-up but you recognize that you need to tap that belly.
Take Home #1
In the emergency department, most of the times you will only need to do a diagnostic tap.
Grab supplies:
Sterile gloves and mask
Sterile OR towel or, even better, a fenestrated drape with adhesive
Chlorhexidine
Long 20 peripheral IV angiocatheters OR syringe + needle from a central line kit OR a spinal needle
60 cc syringe
Sterile cup to collect the fluid sample
Lidocaine, syringe and needle to inject lidocaine
Steps:
Find your pocket with the ultrasound and mark it
Switch to the linear probe and put color on to make sure that you are not going through the epigastric vessels
If you do not have an ultrasound, you will have to go by clinical exam
Positioning:
Have the patient sitting up between 45% and 90 degrees
Roll the patient towards you a bit to allow the bowel to float up and leave the right lower quadrant free of bowel
The best spot is basically the right lower quadrant: 4cm superior and medial to the anterior superior iliac spine
Fill up a 10 cc syringe with lidocaine
Numb the area by making a wheal and then go straight for the peritoneum while aspirating
As soon as you get peritoneal fluid flashback, withdraw the needle to numb the peritoneum and keep injecting in the entire track
Prep with chlorhexidine
Place your drapes
Put the gloves on and tap that belly
Remove about 20 cc and place the peritoneal fluid in the sterile cup and send it to the lab
The Z method:
Right after penetrating the skin, use your other hand to pull the skin up so that the insertion site in the peritoneum and the insertion site on the skin are not aligned in the same tract. After the procedure, this will prevent leakage of peritoneal fluid
If you cannot use the Z method, you can always suture the hole if the leakage does not stop after the procedure is over
Take Home #2
But what if you need to do a therapeutic tap?
Once you have a catheter inside the belly, you can attach a 10 cc syringe
Remove the plunger from the syringe
Insert suction tubing inside the empty syringe
Attach the suction tubing to the wall suction canister
You can also use the Safe-T-Centesis kit if available
You will need the same supplies outlined above (7 items)
In addition you will need the vacuum glass bottles or you can also use the wall suction canisters
Remove the cap on the vacuum glass bottle before you start the procedure
Prep the area and place your drapes
Open the Safe-T-Centesis and put gloves on
Mount the pig tail shaped catheter onto the needle
Make sure that the tubing is closed off to the patient
You have to make a nick in the skin with the blade before the tap
Get peritoneal fluid flash back and slide the catheter into the belly
Place 20 cc of peritoneal fluid in the sterile cup if you need to send it to the lab
In the kit you will find tubing to remove large volume of ascites. One end of the tubing has a sharp tip which will go to the vacuum glass bottle. The other end attaches to the pig-tail catheter
Advantages of the Safe-T-Centesis
The tip is sharp when it hits resistance, it becomes blunt when there is no resistance so you don’t accidentally perforate bowel
Disadvantages of the Safe-T-Centesis
It’s cumbersome and takes more time to set up
Once you open the tray you do not have a lot of sterile space to work with, so remember to save one of your sterile towels for a sterile field
Take Home #3
What if it’s taking too long to do the therapeutic tap and you want remove several liters?
You have a few options to keep removing ascites while you go see other patients:
Tape the catheter to the rail of the bed so it’s suspended in mid air
Use tape to attach the catheter to the patient so that the catheter is suspended in mid air
Sandwich the catheter in between two large tegaderms so the catheter does not kink
Philip Siva Vittozzi Wong, MD is a current third year resident at Stony Brook Emergency Medicine.
References
Safe-T-Centesis - https://www.youtube.com/watch?v=Jme_O2aK3SU
Thanks to Drs Scott Johnson, Erika Newton, Arman Sobhani, Daniel Singer and Justin Larson for additional tricks of the trade
Edited by Bassam Zahid, MD