J-Tip Use for Paracentesis in Adults With Liver Cirrhosis and Ascites

Overview

The purpose of this clinical trial is to evaluate the level of comfort adult patients with cirrhosis of the liver and ascites presenting to Northwestern Memorial Hospital experience during a bedside abdominal paracentesis by numbing the skin with a needle-less device (the J-Tip), instead of using a needle to numb the skin. The main questions it aims to answer are the J-Tip effect upon: 1. Pain during intra-dermal local anesthetic administration 2. Pain during subcutaneous local anesthetic administration 3. Pain during paracentesis 4. Procedure-related anxiety Participants will be randomly assigned to have their skin numbed either in the usual way with a needle or with the J-Tip. Participants will be responsible for having a paracentesis done in their hospital room and answering the survey questions regarding pain experienced during the procedure and how they would feel if they needed to have this procedure performed again. There is also a telephone follow-up survey 2 days after the procedure to ask the participant about their experience post-procedure. We will also collect data about any procedure complications.

The investigators would like to conduct an open label randomized control trial quantifying perception of pain during both administration of local anesthetic and during abdominal paracentesis when superficial (intradermal) lidocaine is administered via needle-free injection system as compared to via 25-gauge needle (standard of care). The study will include at least 110 participants in the emergency room or admitted to a general medical service with cirrhosis and ascites requiring bedside paracentesis, including both diagnostic (only a small sample of fluid removed for testing) and/or therapeutic paracentesis (a large amount of fluid removed to relieve discomfort). The primary physician caring for the patient will determine whether a paracentesis is required (not the study investigators). Patients ≥ 18 years of age presenting to Northwestern Memorial Hospital with cirrhosis of the liver and ascites who require bedside paracentesis will be eligible for this study. Eligible patients will be identified by Emergency Department and Hospital Medicine providers who will notify study investigators. Upon identifying the patients and confirming eligibility through reviewing patients' charts and verbal screening questions, a study team member will approach patients, explain the study, and obtain written informed consent for those patients willing to participate. Patients whose preferred language is not English, those who have previously received or are currently receiving chemotherapy (as the J-Tip is contra-indicated in patients receiving chemotherapy), and those who are otherwise unable to provide informed consent will be excluded. Pregnant patients, prisoners, or other detained individuals will be excluded as well. Upon enrollment, patients will be randomized using a randomization module built into the REDCap project, to either the control (25-gauge needle) or J-Tip arm. Patients will undergo diagnostic and/or therapeutic ultrasound-guided paracentesis as per standard of practice. The only difference between the groups will be the method of administering the superficial (intradermal) anesthesia. Based on randomization, lidocaine will be administered superficially via either 25-gauge intradermal needle (control) or the J-tip Needle-Free injection system. Following this superficial anesthesia injection, both groups will receive deeper subcutaneous lidocaine via a second 22-gauge needle per standard of care. Following the procedure, the patient will be asked by a study coordinator (in person or over the phone) to rate their pain using a numeric rating scale (NRS from 1 to 10; 0= no pain, 10 = extreme pain). Patients will also be asked about anticipated anxiety during future procedures. The thickness of skin tissue and tissue deep to the skin (subcutaneous tissue) overlying the ascites fluid in millimeters as measured by ultrasound will also be measured by the study investigators (Dr. Kahn or Dr. Barsuk) and recorded. Drs. Kahn and Barsuk are on the Hospital Medicine Procedure Service and are routinely consulted to perform paracentesis procedures on patients. Two days following the procedure, a study member will contact the patient (in person or via phone) to inquire about complications including bleeding/bruising and pain following the procedure. Dr. Kahn will also chart review to assess for hemodynamically significant bleed or procedure related complication.