The patient had a significant amount of ascites in the abdominal cavity necessitating paracentesis.
The patient was placed in a semi-Fowlers position. A time out was undertaken to ensure that this is the correct patient and the correct procedure for this patient.
Ultrasound was used to identify a safe area where bowel was limited and fluid was plentiful.
A paracentesis kit was opened.
The patient’s [right] lower abdomen was prepped and cleansed in the usual sterile fashion.
Lidocaine provided in the kit was used to anesthetize the skin over the established safe area.
A 16 gauge blunt tip needle with trocar was utilized to enter the peritoneal space using a “Z-tract” technique.
A total of ___  L of [serous] fluid was removed from the peritoneal cavity and ___ was sent for laboratory evaluation.
The patient had no evidence of hypotension post procedurally. The catheter is removed and a dry sterile dressing was placed. The patient tolerated this procedure quite well and there were no complications.