Methods: We developed a hospitalist-led procedure team with goals of standardizing procedure training for our internal medicine residents, lowering complication rates, and improving throughput by enhancing the timeliness of bedside procedures. Second year IM residents are the primary operators using static or dynamic ultrasound guidance. All procedures are directly supervised by a hospitalist attending. In addition to routine charting, all procedures are logged in a common database including, pre-procedure labs, attempts, technical problems, and complications.
Results: Between July and November 2016, 166 patients were evaluated for paracentesis. After exclusions for insufficient peritoneal fluid or other contraindication, 122 attempts were made with 115 successes (94.3%). Seven cases were aborted due to patient intolerance, bloody ascites, or equipment issues. Cause of cirrhosis in liver patients was not recorded. 17 patients had known or suspected malignant ascites. Patients had a median INR of 1.65 (range 1.0-8.5), platelets 120 10^9/L (22-643) and a creatinine of 1.06 mg/dL (0.3-8.12). 37 patients had AKI at the time of procedure. 7 complications from all causes were recorded, event rate 5.7%. 4 patients (3.3%) had bloody ascites, but no patient developed peri-procedural anemia. Persistent leak occurred in 2 patients (1.6%). One patient (0.8%) had a suspected bowel injury. There were no confirmed cases of secondary infection. Nine patients (7.4%) had technical issues (incomplete drainage, catheter malfunction or catheter repositioned).
Conclusions: In acutely hospitalized patients, ultrasound-guided paracentesis has a very low complication rate. The classic 1986 paper by Runyon found bleeding requiring transfusion in 2 of 229, mostly diagnostic, paracenteses (0.9%). No infections occurred. A 2015 paper by Kurup et al. in the IR setting focused only on major bleeding and found a 0.99% event rate. Prospective data from 515 paracenteses (11.7% ultrasound guided) on cirrhotics by DeGottardi et al. from 2009 had 10.5% overall complications and 5.4% technical problems. Our data shows that consistent ultrasound guidance may offer decreased complications over traditional practice. A larger sample is needed to confirm this effect, but remains an exciting confirmation to our practice.
To cite this abstract:Chopski, BD; Malik, M; Garber, AM; Modi, S; Miller, R; Meliagros, P; Ritter, E . PICTURE MAKES PERFECT: DOES ULTRASOUND GUIDANCE REDUCE COMPLICATIONS IN PARACENTESIS?. Abstract published at Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev. Abstract 71. Journal of Hospital Medicine. 2017; 12 (suppl 2). https://www.shmabstracts.com/abstract/picture-makes-perfect-does-ultrasound-guidance-reduce-complications-in-paracentesis/. Accessed May 24, 2019.