Blog → Left, Right, or Center? Best Location for Paracentesis

Left, Right, or Center? Best Location for Paracentesis

Listen to this article
0:00 –:–

Written by Aaron Lacy

Spoon Feed
When using a midline approach to paracentesis, there were no instances of hemorrhage compared to lateral. However, there is fine print to consider before changing your practice…

A lateral approach is so mid…
While generally safe, hemorrhage from paracentesis can be devastating. This group compared hemorrhage rates between a lateral and midline approach to catheter placement. All patients had ultrasound-guided preprocedure site selection. When comparing 4,563 paracentesis attempts in 1,798 patients, they found no instances (0/230) of hemorrhage in patients who underwent a midline approach compared to a 1.4% instance (60/4283) of hemorrhage during the lateral approach (p=0.03). There was a higher MELD 3.0 score in the group that received midline paracentesis (22 vs 25, p < 0.001).

So, should we all switch to the midline approach?

How will this change my practice?
These results are intriguing, but I think this study justifies a conclusion line of “more research is needed.” I won’t totally switch from lateral to midline due to a few lingering concerns.

  • First, there is an extremely low number of patients who underwent the midline approach compared to the lateral approach, which limits the results.
  • Second, the midline approach punctures the linea alba, an avascular structure. This could explain the decrease in hemorrhage, but I worry about potential downstream consequences from repeated trauma to this structure. Cirrhotic patients typically need multiple paracentesis over the course of their illness and frequently have distended abdomens, a potential recipe for developing a ventral hernia.
  • While not explicitly stated, it appears that every patient in this study received a therapeutic paracentesis, which involves catheter placement into the peritoneum (typically 8 Fr in size). In the ED setting, I am often only performing diagnostic paracentesis with an 18G or smaller needle, which is associated with significantly less hemorrhage risk than therapeutic taps, limiting its applicability to me. 

This study does reassure me that if I don’t see a satisfactory lateral site, I can consider a midline approach to get diagnostic studies.

Source
Lateral Versus Midline: A Retrospective Review of Paracentesis Site Location and Risk of Hemorrhagic Complication. Crit Care Med. 2025 Dec 1;53(12):e2698-e2705. doi: 10.1097/CCM.0000000000006883. Epub 2025 Sep 26. PMID: 41020659.

View JournalFeed Critical Appraisal

Critical Appraisal

Study Identification

Title: Lateral Versus Midline: A Retrospective Review of Paracentesis Site Location and Risk of Hemorrhagic Complication
Authors: Josef Miller, Tracy Dinh, Cole Pieroni, Agostina Velo, Anne Pohlman, Gaurav Ajmani, Krysta Wolfe, Bhakti Patel, John P. Kress
Journal: Critical care medicine
Year: 2025
DOI: 10.1097/CCM.0000000000006883
Trial Registration: Not reported
Country / Region: United States
Setting: Single academic center

Background

Paracentesis is a common procedure for patients with ascites due to cirrhosis, malignancy, or heart failure. It carries a risk of hemorrhage, which may be reduced by using a midline approach due to the avascular nature of the linea alba.

Study Question

Does the midline approach to paracentesis reduce the risk of hemorrhagic complications compared to the lateral approach?

Study Design & Conduct

Study Design: Retrospective chart review
Prospective / Retrospective: Retrospective
Multicenter: No
Unit of Allocation: Not applicable
Unit of Analysis: Paracentesis events
Randomization Method: Not applicable
Allocation Concealment: Not applicable
Blinding: Not applicable
Follow-up Duration: 7 days

Population

Inclusion Criteria:
  • Patients undergoing ultrasound-guided paracentesis
Exclusion Criteria:
  • Insufficient data to determine procedural location
Number Screened: Not reported
Number Enrolled: 1798
Number Analyzed: 4563
Key Baseline Characteristics
Age: Median 61 years
Sex: 45.2% female
Disease Severity: Not reported
Care Setting Distribution: Inpatient
Additional Baseline Characteristics
  • Median INR: 1.4
  • Median platelet count: 147
  • Median hemoglobin: 9.4

Exposures / Interventions

Primary Exposure / Intervention
Description: Midline paracentesis approach
Definition / Dose: Not applicable
Timing: During paracentesis procedure
Classification Method: Procedure notes
Protocolized / Discretionary: Discretionary
Comparator / Reference
Description: Lateral paracentesis approach
Definition: Not applicable

Outcomes & Results

Primary Outcomes
Post-paracentesis hemorrhage
Definition: CT imaging with evidence of hemorrhage at the procedural site within 7 days requiring intervention or resulting in death
Time Point: Within 7 days
Measurement Method: CT imaging
Results: 0% in midline vs. 1.4% in lateral; p = 0.03
Secondary Outcomes

Risk of Bias

Risk of Bias - ROBINS-I
  • Confounding (Some concerns): Potential confounders like operator skill and patient selection not fully controlled.
  • Selection of Participants (Low): All eligible patients within the study period were included.
  • Classification of Interventions (Low): Intervention classification was clear and based on procedural notes.
  • Deviations from Intended Interventions (Low): No deviations from the intended intervention were reported.
  • Missing Data (Low): Data on hemorrhage outcomes were complete for all procedures.
  • Measurement of Outcomes (Low): Outcome measurement was objective and consistent.
  • Selection of the Reported Result (Low): All relevant outcomes were reported.
Transparency
Funding Disclosed: TRUE
COI Statement Present: TRUE
This critical appraisal is generated using a structured framework applied to the full text of the original article and is presented separately from the physician’s commentary.

Leave a Reply