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To determine if emergency center ultrasound (ECUS) can be of value to emergency physicians in the evaluation of possible ascites and accompanying decisions to perform emergent paracentesis.During a 7-month period, patients suspected of having ascites and potentially requiring paracentesis were prospectively entered into a randomized study in an urban public hospital emergency center (>140 000 annual visits). Patients were randomized to receive paracentesis using the traditional or the bedside ECUS-assisted technique. Indications for paracentesis included known liver disease and obvious ascites as well as suspected ascites or suspected subacute bacterial peritonitis. Participating physicians had received a minimum of 1 hour of formal didactic ultrasound training that included gallbladder, renal, vascular, and bladder studies as well as the focused abdominal sonography for trauma examination for trauma and the detection of ascites. A portable Terason 2000 laptop ultrasound machine with a 5-MHz probe was used to scan the patients. Data collected included the patients' characteristics, estimation of ascitic fluid volume, number of attempts made to obtain fluid, speed of paracentesis, and the operator's overall evaluation of the ECUS-assisted technique, if used.Of 100 enrolled patients, 56 received the ECUS-assisted technique. Of 42 patients with ascites, 40 (95%) were successfully aspirated and 14 (25%) did not receive paracentesis because no ascites or insignificant amount of ascites was visualized. One patient was noted to have a large cystic mass in the left lower quadrant and another patient had a ventral hernia. Of the 44 patients randomized to the traditional technique, 27 (61%) were successfully aspirated. In 17 (39%) of these patients, fluid could not be obtained using traditional methods. Of these 17 failed attempts by traditional methods, 15 patients received ECUS in a “break” from the study protocol. Ascitic fluid was obtained in 13 of these 15 patients; of the 2 remaining patients, 1 did not have enough fluid to be sampled and the other had no fluid visualized.Ninety-five percent (P = .0003) of the patients who were randomized in the ECUS group and in whom a needle paracentesis was performed had ascitic fluid successfully obtained, as compared with the traditional method group.