Take My Picture, Please!   Does Ultrasound Guidance Reduce Complications In Inpatient Paracentesis?

Ritter, Evan

TAKE MY PICTURE, PLEASE! DOES ULTRASOUND GUIDANCE REDUCE COMPLICATIONS IN INPATIENT PARACENTESIS?

Benjamin Chopski, D.O. ¹, Manpreet Malik, MD², Adam Garber, MD, FACP³, Sarika Modi, MD², Pete Meliagros, MD⁴, Becky Miller, MD², Evan Ritter, MD², ¹Virginia Commonwealth University, Henrico, VA; ²Virginia Commonwealth University; ³Virginia Commonwealth University, Moseley, VA; ⁴VCU Health, Glen Allen, VA

Meeting: Hospital Medicine 2018; April 8-11; Orlando, Fla.

Abstract Number: 113

Category: Research

Sub-Category: Outcomes Research

Keywords: Paracentesis, Procedure Team, Procedures, Ultrasound

Background: Ultrasound-guidance has become the standard for bedside procedures in the emergency and inpatient settings due to its perceived impact on first attempt success and complications. Prior literature on paracentesis notes a 10% rate of overall complications, 5% rate of technical problems, and a 1% rate of bleeding. However, existing cohorts often include outpatients or do not use ultrasound consistently. Our aim is to establish whether the risk bleeding or other injury is similar for hospitalized patients undergoing ultrasound-guided paracentesis.

Methods: We developed a hospitalist-led procedure team with the goals of standardizing resident procedure training, lowering complication rates and improving timeliness for bedside procedures. Internal Medicine residents are the primary operators and all procedures are directly supervised by a hospitalist attending. Consults are logged in a REDCap database including demographics, labs, attempts, technical problems and complications.

Results: We analyzed 503 inpatient consults over sixteen months. Patients had a mean age of 56.9 years. (SD 10.4). Most patients were Caucasian or African American, at 57% and 38% respectively. Thirty-five patients had known or suspected malignant ascites prior to the procedure.After exclusions for insufficient peritoneal fluid and other contraindications, 392 attempts were made with a 97% success rate. Eleven cases were aborted due to patient intolerance, unexpected bloody ascites, or technical problems such as difficulty passing the catheter through the peritoneum.
Compilations were reported in 7% of procedures. The most common complication was ascitic leak in 11 cases (3%). Five (1.3%) cases had unexpected bloody ascites. Three patients developed post-procedural anemia with one possible death from hemoperitoneum. Two patients had hypotension without bleeding. No patients developed a secondary infection.
Technical issues occurred in an additional 4% of patients. In five cases, the team was unable to obtain ascitic fluid. Difficulty passing the drainage catheter through the peritoneum, difficult drainage, operator error or defective equipment occurred in four or less cases each. Cases with technical issues accounted for nine of the eleven aborted cases, the other two being due to patient intolerance and bloody ascites.

Conclusions: This study demonstrates the safety of ultrasound guided paracentesis in the inpatient setting. We found a lower overall complication rate compared to other cohorts. This is especially important given the higher acuity of patients in the inpatient setting. This confirms our current practice of a procedure team providing consistent ultrasound-guided procedures.