Paracentesis Note

[Read Paracentesis]

Date of surgery:

Procedure: Paracentesis

Primary Surgeon:

Supervising Surgeon:

Attending Physician

Referral: Primary Medical Doctor.  

Indications: ascites.  

Confirmed correct: Patient, Procedure, Side.  

Procedure consent form signed: Yes.  

Location: LLQ.  

Preparation: Chlorhexidine.  

Anesthesia: 1% lidocaine 10 ccs subcutaneous.  

Technique: Pt was identified verbally in Room 12 of SRMC Emergency Department.  Any and all pt questions were answered at that time.  Procedure was discussed with patient and mother, including endpoints of procedure, risks, benefits and alternative measures.  Patient voiced understanding and agreed to procedure.  Informed consent was then documented.

A time-out was completed verifying correct patient, procedure, site, positioning.Ultrasound guidance was used.  Appropriate area confirmed and marked in the left lower quadrant 1/3 between the iliac crest and umbilicus. Patient was positioned in the supine position, prepped and draped in usual sterile fashion. 10 mL 1% Lidocaine was used to anesthetize the area.  An 11 gauge scalpel was used to make a 2 mm incision.  An 18-gauge over-the-needle catheter was introduced into the abdomen in usual fashion via the Z-track method.  Once ascitic fluid was obtained, advancing the needle was halted and the catheter was carefully guided over the needle.  The needle was then then removed.  Fluid was removed in normal fashion via the 3 way stopcock.  When the procedure had been completed, the catheter was removed quickly while the patient held their breath at end expiration.  No “leak” noted from the area.  The site was covered with an occlusive dressing, and the patient was transferred to bed for recovery.  Blood loss was minimal and patient tolerated the procedure well.  Fluid samples were sent to the laboratory for evaluation.

Post procedure patient condition: Improved.  

Complications: None, Pt tolerated procedure well