Background: Paracentesis is a commonly performed bedside procedure in hospitalized patients. It is often necessary for patients who are taking anticoagulant therapies and/or have disorders of hemostasis. Concerns about bleeding complications often lead to care delays, blood product transfusions, medication changes, and costly labs.

Purpose: This study evaluates the safety and clinical outcomes for a less invasive modification to the standard paracentesis technique.

Description: Our Hospitalist Procedure Service performs bedside, ultrasound-marked therapeutic paracenteses on medical and surgical inpatients in a 796-bed academic teaching hospital. We recommend INR <2 and platelet count >50 x109/L as the safe cutoffs for a standard paracentesis, which uses a scalpel incision to allow for the insertion of an 8 Fr. catheter over 18 Ga. x 7.5” needle. On October 1, 2015, we implemented a modification using a 20 Ga. x 1.88” or 18 Ga. x 2.5” angiocatheter for deeper tissue anesthesia and ascites removal without a scalpel incision. All other technical aspects were identical. Paracenteses were primarily performed by internal medicine interns and supervised by a hospitalist with procedural expertise. Data were prospectively collected on patient demographics, clinical characteristics such as periprocedural medications and lab values (e.g. platelet count, INR), and outcomes including volume removed and any complications.
From October 1, 2015 through November 27, 2017, our service performed 636 therapeutic paracenteses, of which 91 (14.3%) underwent a modified technique. There was no difference in the age, sex, or referring service of patients receiving the modified versus standard technique (all p>0.05). Patients who underwent the modified technique were more likely to be ICU level acuity (p<0.01), have received warfarin (p<0.01), have a lower platelet count (p=0.03), and have a higher INR (p<0.01) immediately before the procedure. The modified technique removed an average of 3,101mL (SD 2,141mL) of ascites, compared to the standard technique removing 3,989mL (SD 2,204mL). There were no deaths in our cohort and no difference in the rate of complications, including major and minor bleeding, bowel or other organ injury, ascites leak, or uncontrolled pain (all p>0.30). The modified procedure added 2-3 minutes of time for every liter of ascites removed.

Conclusions: We describe a safe and effective modification to the standard paracentesis for hospitalized patients. This modification has allowed our service to perform paracenteses on patients with higher clinical acuity, with broader coagulopathy and thrombocytopenia than usual safety cutoffs, and on therapeutic anticoagulation when compared to our standard practice. We plan further follow-up and analysis of this cohort to investigate the impact of this modified paracentesis technique on anticoagulation interruptions, laboratory utilization, periprocedural blood product use and transfusion-related events, length of stay, and overall costs.