Lateral Versus Midline: A Retrospective Review of Paracentesis Site Location and Risk of Hemorrhagic Complication.

Abstract

Objectives: Patients who have cirrhosis, malignancy, or heart failure frequently accumulate ascitic fluid in their peritoneal cavity. Percutaneous drainage of ascites is a common procedure to provide diagnostic and/or therapeutic benefit to the patient; however, this procedure is associated with a small but life-threatening risk of hemorrhage. Given the avascular nature of the linea alba, it was hypothesized that a midline approach would reduce the risk of hemorrhage.

Data sources: Data were collected from the electronic medical record. This review was authorized by the University of Chicago, Institutional Review Board 20-0083.

Study selection: Using the electronic medical record, 1798 patients were identified using International Classification of Diseases, 9th revision and International Classification of Diseases, 10th revision codes between January 1, 2011, and January 1, 2020.

Data extraction: We conducted a retrospective chart review of 1798 patients who underwent 4563 percutaneous abdominal paracentesis events with ultrasound guidance. Four thousand five hundred thirteen of those procedures had information about procedure location. The location of catheter placement, lateral vs. midline, was recorded in conjunction with occurence rate of post-paracentesis clinically significant hemorrhage, defined as CT imaging with evidence of hemorrhage at the procedural site within 7 days of paracentesis that required either blood transfusion, angiographic intervention, or resulted in death. Baseline characteristics were also collected, including age, sex, body mass index, volume of ascites drained, baseline hemoglobin, platelet count, international normalized ratio, serum sodium, creatinine, bilirubin, albumin, and etiology of ascites. Among paracentesis events for patients with a diagnosis of cirrhosis (n = 2497), 2206 has sufficient data to calculate a Model for End-Stage Liver Disease (MELD) 3.0 score and 2202 had sufficient data to determine Child-Pugh Classification.

Data synthesis: Among patients receiving paracentesis, the overall occurence rate of hemorrhage was 1.3% (60/4563). There was a statistically significant reduction in the occurence rate of hemorrhage among patients who underwent midline percutaneous catheter placement (0/230) compared with lateral percutaneous catheter placement (60/4283; p = 0.03). Among patients with cirrhosis, patients undergoing lateral paracentesis (n = 2086) had a mean MELD 3.0 score of 22 (sd, 8.46) and patients undergoing midline paracentesis (n = 118) had a mean MELD 3.0 score of 25 (sd, 8.13). These groups had a statistically significant difference by Mann-Whitney U test (p ≤ 0.001) with a standardized effect size of 0.071. Logistic regression was performed to identify patient variables that correlated with hemorrhage. Among these, only serum bilirubin nearly approached significance (p = 0.07). No baseline variable had an odds ratio that did not cross 1.0.

Conclusions: These data suggest midline paracentesis may reduce the risk of post-procedural hemorrhage among patients undergoing paracentesis.