Paracentesis performed in an outpatient setting by gastrointestinal endoscopy assistants is safe

Aug 18 2004

Large-volume paracentesis is a treatment used to remove excess fluid in the abdominal cavity resulting from such conditions as cirrhosis of the liver or cardiac failure. It is normally performed as an inpatient procedure due to possible complications, which may include infection, bleeding, and bowel perforation.

In a study led by Catherine M. Grabau at the Division of Gastroenterology and Hepatology and Internal Medicine at the Mayo Clinic in Rochester, Minnesota, and published in the August issue of Hepatology, gastrointestinal endoscopy assistants performed large-volume paracenteses on outpatients in order to determine how many procedures were required to develop competence and the amount of time needed to perform each procedure.

Hepatology, the official journal of the American Association for the Study of Liver Diseases (AASLD), published by John Wiley & Sons, Inc. is available online via Wiley InterScience.

The gastrointestinal endoscopy assistants, all of whom were licensed practical nurses, performed 1,100 large-volume paracenteses in 628 patients during the period between June 1994 and June 2001. During training, the supervising physician discussed the procedure in depth with the trainee and performed the first paracentesis, with the trainee assisting. The next two procedures were performed by the gastrointestinal endoscopy assistant with the physician assisting, and the next four to six procedures were done by the assistant independently, under the physician's observation. The number of independent procedures performed by the trainee before the supervising physician was comfortable with the level of skill ranged from three to seven. In the 23 patients in which the gastrointestinal endoscopy assistants determined that paracentesis was not feasible, the supervising physician agreed with the assessment in all cases.

The study also examined the risk of possible complications, in particular whether the risk of bleeding was associated with thrombocytopenia (reduced platelet count) or prolonged prothrombin (clotting) time. None of the patients in the study experienced significant bleeding or complications, even those whose platelet count was significantly below normal range and those with prolonged prothrombin time.

The authors conclude that paracentesis performed in an outpatient setting by gastrointestinal endoscopy assistants is safe and efficient, and can usually be accomplished in two hours. The major benefit is a significant saving in physician time (limited to a maximum of 10 supervised procedures) with no increased risk to the patient. Further, since the guidelines of the Joint Commission on Accreditation of Healthcare Organizations recommend discontinuing the practice of having gastrointestinal endoscopy assistant carry out the procedure, the authors suggest that the guidelines may need to be readdressed.