✓ Identify etiology of ascites
✓To alleviate abdominal pressure or respiratory
distress in hemodynamically stable patients.
✓To diagnose spontaneous bacterial peritonitis.
✓Diagnose metastatic cancer.
✓To diagnose blood in peritoneal space in case
13. Anesthetize the skin over the insertion site
With the catheter mounted to the syringe,
puncture the anesthetized skin.
Needle is inserted at a 45 degree angle or
with z tracking technique.
15. After the procedure, gently remove the
catheter, and apply direct pressure to the
Observe the characteristics of the fluid, and
send it for the appropriate studies. If the
insertion site is still leaking after 5 minutes of
direct pressure, suture the site.
Apply a pressure dressing.
16. For a therapeutic tap, do not remove more
than 500 ml in ten minutes.
One liter is the maximum that should be
removed at one time.
Removal of 5L or more than 5 is considered as
Large volume paracentesis.
19. Post Procedure
Observe patient for 30 minutes for
signs/symptoms of hypotension, bleeding, or
Provide post-procedural analgesics as needed.
i. Persistent leakage of ascitic fluid at the needle
ii. Abdominal wall hematoma or bleeding
iv. Perforation of surrounding vessels or viscera.
v. Hypotension after large volume fluid removal
(more than 5 L to 6 L).
vi. Electrolyte imbalance
❖ For diagnostic purpose
To differentiate transudate from exudate
❖ As treatment procedure
To drain large amounts of pleural fluid
To equalize pressure on both sides of the thoracic cavity
Relieve shortness of breath and pain
Instillation of medication into the pleural space
25. Pre procedure
➢Assess for known allergies, especially to local
➢ If unable to sit, the patient should lie at the edge
of the bed on the affected side with the ipsilateral
arm over the head and the midaxillary line
accessible for the insertion of the needle.
Elevating the head of the bed to 30 degrees
➢Instruct the patient to refrain from coughing,
breathing deeply or moving during the procedure
27. The usual site for insertion of the
thoracentesis needle is the posterolateral
aspect of the back.
Mark the top of the dullness by washable ink
mark or indenting the skin.
Incision- below the fluid level.
Confirm site based on chest x-ray and
percussing out the fluid level.
28. Post procedure
• Sterile dressing is fixed in place.
• Obtain post-procedure chest x-ray results. The x-ray
verifies that there is no pneumothorax.
• Record total amount of fluid withdrawn, nature of fluid
its color and viscosity.
• A specimen container with formalin may be needed if
a pleural biopsy is to be obtained.
• Evaluate the patient at intervals for increased
respiration rate, asymmetric lung movement, vertigo,
tightness in the chest area, uncontrolled cough with
blood-tinged mucus, rapid pulse and signs of
▪ Re expansion pulmonary edema(REPE)
▪ Respiratory distress
▪ Air embolism
▪ Dyspnea and cough
▪ Cardiac tamponade
35. Pericardial effusion v/s Tamponade.
The acute or chronic accumulation of fluid in
the pericardial space (between the parietal
and the visceral pericardium) is pericardial
Cardiac tamponade, also known as
pericardial tamponade, when fluid in the
pericardium builds up, resulting in
compression of the heart.
• Injury to the sac or heart from a medical procedure
• Heart attack
• Severe kidney failure, also called uremia
• Autoimmune diseases
• Bacterial infections, including tuberculosis
38. Pre procedure
➢ Prior to procedure: Use echocardiogram or
ultrasound to identify the fluid.
➢ Patients who are receiving anticoagulants
should discontinue those medications prior to
➢ Raise the blood pressure throughout the
39. ➢ Procedure is done under imaging guidance.
➢ Patient placed on supine position
➢ The skin is sterilized and local anesthetic given
➢ Use 3 inch, 16-20 gauge needle
➢ The most standard location is through
the infrasternal angle/subxiphoid approach.
➢ Another location is through the 5th or
6th intercostal space at the left sternal border at
the cardiac notch also called as parasternal
42. ➢ After the procedure
➢The tube is left connected to the drainage.
➢Echocardiogram will be performed to monitor
the clearance of fluid.
➢The fluid should be tested for identification of
44. Lumbar puncture/ Spinal tap
Procedure in which a needle is inserted into
the spinal canal to collect cerebrospinal
fluid (CSF) for diagnostic testing.
❖ Diagnose bacterial, fungal and viral infections, including
❖ Inflammatory conditions of the nervous system, such as
multiple sclerosis(oligoclonal band) and Guillain-Barre
❖ Malignancies of the brain or spinal cord.
❖ Subarachnoid hemorrhage
❖ Inject anesthetic medications or chemotherapy drugs into
❖ Inject dye (myelography) or radioactive substances into
cerebrospinal fluid to make diagnostic images.
CT brain, especially in the following situations
Recent history of seizure
Focal neurological signs
Abnormal respiratory pattern
Bleeding diathesis (relative)
Decreased platelet count (<50 x 109/L)
51. • Autoimmune conditions, such as multiple sclerosis and
Guillain-Barre syndrome, can lead to an inflammatory
response, which can be detected by the presence of
autoantibodies in the CSF.
• CSF analysis test to check for primary and metastatic
cancerous tumors in the CNS.
• Diagnose Alzheimer's disease, by measuring levels of
amyloid beta 1-42 (Aß1-42) and p- and t- tau proteins.
• In cases of infectious diseases meningitis and encephalitis,
CSF test can done to find out if the cause is viral, fungal,
bacterial, or due to a parasite, which will influence the
course of treatment.
• Intracranial bleeding
55. When is Arthrocentesis Performed?
❖ Identification of the etiology of Arthritis.
❖ Therapeutically for pain relief, drainage of
❖ For Relieving pressure in the joint
❖Injection of medications
57. In Gout
There is increased uric acid,monosodium urate
Calcium pyrophosphate is present in chondrocalcinosis
Cholesterol crystals is common in RA
Synovial glucose level
Lowest in septic arthritis.
Glucose is also low in rheumatoid arthritis.
59. ❖ In bacterial arthritis, there is an increased level of
protein and lactate.
❖ Rheumatoid arthritis shows more lymphocytes
❖Gram staining is done to distinguish gram
positive and negative bacteria
❖AFB stain is done to rule out tubercle bacilli.
❖Complement level is done which is low in:
Systemic lupus erythematosus.
i. No absolute contraindications for diagnostic
ii. Do not inject steroids into a joint which is
– Overlying cellulitis
– Joint prosthesis
Betadine or Chlorhexadine
– Small syringe (6-12cc) for injection of local anesthetic
– Large syringe (one 60cc or two 30cc) for aspiration
– 18 gauge: knee
– 20 gauge: most other joints
– 25 gauge: MTP joints
– 27 gauge for anesthetic injection
Collection tubes (red top and purple for crystal analysis)
Ventriculoperitoneal (VP) shunt is a medical
device that relieves pressure on the brain
caused by fluid accumulation. VP shunting is a
surgical procedure that primarily treats a
condition called hydrocephalus. This condition
occurs when excess cerebrospinal fluid (CSF)
collects in the brain's ventricles.
72. Different Kinds of Shunts
1. The abdomen (ventriculo-peritoneal or
2. The lung (ventriculo-pleural shunt)
3. The heart (ventriculo-atrial shunt)
73. Ventriculoperitoneal shunts consist of a valve
and two tubes, called catheters, which drain
One catheter drains fluid from the brain out of
a small hole . This is called the inflow catheter.
The other runs under the skin, taking the fluid
to a drainage site elsewhere in the body. This
is called the outflow catheter.
74. There are two types of ventriculoperitoneal shunt
With a nonprogrammable shunt, the doctor
programs the valve so that it activates whenever
the fluid reaches a certain volume. It is not
possible to adjust a nonprogrammable shunt
A programmable shunt, however, has an external,
adjustable valve that the doctor can re adjust at
any time according to the person's needs.
• The surgeon makes a skin incision behind the ear. Another small surgical
cut is made in the belly.
• A small hole is drilled in the skull. One end of the catheter is passed into
a ventricle of the brain.
• A second catheter is placed under the skin behind the ear. It is sent down
the neck and chest, and usually into the belly area.
• A valve is placed underneath the skin, usually behind the ear. The valve
is connected to both catheters. When extra pressure builds up around
the brain, the valve opens, and excess fluid drains through the catheter
into the belly or chest area. This helps lower intracranial pressure.
78. Risks and complications may
o Shunt malfunction
81. HYDROCELE ASPIRATION
Accumulation of serous fluid around testicle.
It is often caused by fluid secreted from a
remnant piece of peritoneum wrapped
around the testicle, called tunica vaginalis.
c. Fournier's gangrene
d. Scrotal calculi
e. Testicular ischemia
f. Calcification of the sac wall
g. Rupture of hydrocele sac
h. Hernia of the hydrocele sac in long standing
cases when tension of the fluid within tubica
causes herniation through dartos muscle.
Hydrocele is held tense by an assistant
Incision depending upon size is made over the most
prominent part of the swelling parallel to the median
raphe of the scrotum.
Layers opened :skin, dartos, external spermatic fascia ,
cremasteric fascia , internal spermatic fascia.
At this stage hydrocele sac is visible and is delivered
outside the incision
Hydrocele fluid is drained by using trocar and cannula
92. Mootravridhi(AH.chikitsa 13)
❑ First fomented and then a piece of cloth should
❑ A puncture should then be made in the bottom
of the sac with a Vrihimukha instrument, on
either side of the Sevani.
❑ A tube open at both ends should be introduced
and the accumulated fluid should be let out. The
tube should then be taken off and the scrotum
should be tied up with a bandage(Sthagika) and
the incidental ulcer should be healed.