Procedure: Large volume paracentesis with ultrasound guidance

CLINICAL HISTORY:

Volume: _____ cc clear yellow fluid

Access site: ____ quadrant with ultrasound

Complications: None immediate.

Procedure:

The risks, benefits, and alternatives to the procedure and sedation were explained to the patient. The specific risks of bleeding, infection, and damage to organ or bowel were detailed and accepted. Written informed consent was obtained. A timeout was performed.

The anterior abdominal wall was prepped and draped in sterile fashion. Ultrasonographic evaluation of the abdomen was carried out and an appropriate entry site chosen. Images were stored to PACS.

Using local anesthetic, the peritoneal cavity was accessed with a centesis catheter. Needle entry was documented and an image stored.

The catheter was attached to a Vacutainer bottle wall suction and approximately cc clear yellow fluid were drained. Follow-up ultrasound was performed, demonstrating no significant residual fluid.

The catheter was removed, and a sterile dressing was applied.

The procedure was well tolerated without immediate complication.

Findings:

There is ______ peritoneal fluid.

Aspirated fluid was clear.

______cc were removed without incident.

Impression:

Successful ultrasound guided large volume paracentesis.