Z tracking for paracentesis

Z-tracking is a way to minimize fluid leakage after performing a paracentesis. The skin is slowly pulled down while the needle is advanced in 5 mm increments, aspirating as you go. If it is a therapeutic paracentesis, use a large bore needle (14) to reduce the amount of time it takes to drain.

Indications for paracentesis

  • New onset ascites
  • Hospitalization of a patient with ascites
  • Clinical deterioration of an inpatient or outpatient with ascites
    • Fever
    • Abdominal pain
    • Abdominal tenderness
    • Hepatic encephalopathy
    • Peripheral leukocytosis
    • Deterioration in renal function
    • Acidosis

Routine tests

  • Cell count and differential
  • Albumin concentration (you then compare this to serum albumin)
  • Total protein concentration
  • Culture


DIC, primary fibrinolysis

serum to aspires gradient (SAAG)

Used to identify the presence of portal hypertension

SAAG = Serum albumin – Ascites albumin

≥11 g/L: portal hypertension
<11 g/L: not portal hypertension
If heart failure is the cause, the gradient can be narrowed by diuresis, but in cirrhosis the gradient does not change unless the portal pressure drops significantly

Clotting Cascade

It seems as though the clotting cascade is something you can study over and over again and it never sticks.

The important things to know are:

HEPARIN affects factor VIII in the INTRINSIC pathway and this is measured using PTT (partial thromboplastin time)
WARFARIN affects the vitamin K dependent synthesis of some clotting factors (purple in the image), particularly factor VII in the EXTRINSIC pathway and this is measured using PT (prothombin time) or INR (International Normalized Ratio, which is derived from the PT)