Written by Aaron Lacy
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.
