Difference between revisions of "Thoracentesis"

(Relative Contraindications)
 
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==Indications==
 
==Indications==
*New-onset pleural effusion (except obvious CHF-induced effusion)
+
*New-onset pleural effusion (except obvious [[CHF]]-induced effusion)
 
*Symptomatic pleural effusion
 
*Symptomatic pleural effusion
  
==Relative Contraindications==
+
==Contraindications==
 
{{Thoracentesis with coagulopathy}}
 
{{Thoracentesis with coagulopathy}}
  
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*Thoracentesis kit
 
*Thoracentesis kit
 
*Sterile gloves
 
*Sterile gloves
*Chlorhexidine scrub
+
*Chlorhexidine or betadine scrub
 
*Evacuated container
 
*Evacuated container
*Ultrasound
+
*[[Ultrasound]]
 
 
===Labs===
 
**Protein, gluc, LDH, gram stain, culture (blood cx bottle), cell count, amylase, pH, TB (adenosine deaminase), fungal, cytology
 
**Send serum LDH, protein at same time
 
  
 
==Procedure==
 
==Procedure==
 +
[[File:Gray530.png|thumb|Left pleura cavity (viewed from left) showing intercostal bundles (vein, artery, and nerve) under ribs.]]
 
*Choose insertion site/positioning
 
*Choose insertion site/positioning
 
**Upright position in mid-scapular or posterior axillary line (usual technique)
 
**Upright position in mid-scapular or posterior axillary line (usual technique)
**Lateral decubitus position w/ fluid side down in post axillary line (if cannot sit up)
+
**Lateral decubitus position with fluid side down in post axillary line (if cannot sit up)
**Supine w/ head elevated as much as possible in midaxillary line (chest tube location)
+
**Supine with head elevated as much as possible in midaxillary line (chest tube location)
*Prep skin
+
*Cleanse skin with chlorhexidine or betadine
*Anesthetize skin
+
*Anesthetize skin and subcutaneous tissue - raise wheal and advance/inject along superior aspect of lower rib (avoid NV bundle)
**Raise wheal and advance/inject along superior aspect of lower rib (avoid NV bundle)
+
*Make small skin nick with scalpel
*Puncture skin w/ scalpel (optional)
+
*Insert/advance needle while continuously aspirating until pleural space is entered
*Insert/advance catheter while continuously aspirating until pleural space is entered
+
*Advance catheter into pleural space while removing needle
*Drain fluid
+
*Connect tubing to catheter and to evacuated container and remove desired amount of fluid
*Post-procedure CXR only necessary if:
+
 
 +
*Obtain post-procedure CXRif:
 
**Multiple needle passes required
 
**Multiple needle passes required
 
**Air is aspirated
 
**Air is aspirated
 
**Risk of adhesions
 
**Risk of adhesions
 
**New-onset of symptoms during the procedure (chest pain, dyspnea)
 
**New-onset of symptoms during the procedure (chest pain, dyspnea)
**pts at high risk for decompensation from small ptx (lung dz, on ventilator)
+
**Patient at high risk for decompensation from small pneumothorax (lung disease, positive pressure ventilation)
  
 
==Complications==
 
==Complications==
*Pneumothorax (4-19%)
+
''Ultrasound-guidance significantly reduces complication rates''<ref>Mercaldi CJ, Lanes SF. Ultrasound guidance decreases complications and improves the cost of care among patients undergoing thoracentesis and paracentesis. Chest. 2013;143(2):532-538. doi:10.1378/chest.12-0447</ref> video<ref>5 Minute Sono – Thoracentesis https://www.coreultrasound.com/5ms-thora/</ref>
 +
*[[Pneumothorax]] (4-19%)
 
*Cough (9%)
 
*Cough (9%)
 
*Infection (2%)
 
*Infection (2%)
*Hemothorax
+
*[[Hemothorax]]
*Splenic rupture
+
*[[Splenic injury]]
*Reexpansion pulmonary edema
+
*[[Diaphragmatic injury]]
**Dyspnea, tachypnea, cough, frothy sputum
+
*[[Hepatic injury]]
**Tx with aggressive volume resuscitation
+
*[[Vascular injury]]/bleeding
 +
*[[Air embolism]]
 +
*Reexpansion [[pulmonary edema]]
 +
**Treatment should include supportive care with [[noninvasive ventilation]] as needed
 +
**Diuresis is not a primary treatment for reexpansion pulmonary edema
  
 
==See Also==
 
==See Also==
 
[[Pleural Effusion]]
 
[[Pleural Effusion]]
  
==Source==
+
==References==
*Robert and Hedges
+
<references/>
*Tintinalli
 
  
 
[[Category:Procedures]]
 
[[Category:Procedures]]
[[Category:Pulm]]
+
[[Category:Pulmonary]]

Latest revision as of 19:55, 8 April 2021

Indications

  • New-onset pleural effusion (except obvious CHF-induced effusion)
  • Symptomatic pleural effusion

Contraindications

Thoracentesis if coagulopathic

  • Platelets <50K[1]
  • INR >2x normal[1]
  • Mechanical ventilation

Equipment Needed

  • Thoracentesis kit
  • Sterile gloves
  • Chlorhexidine or betadine scrub
  • Evacuated container
  • Ultrasound

Procedure

Left pleura cavity (viewed from left) showing intercostal bundles (vein, artery, and nerve) under ribs.
  • Choose insertion site/positioning
    • Upright position in mid-scapular or posterior axillary line (usual technique)
    • Lateral decubitus position with fluid side down in post axillary line (if cannot sit up)
    • Supine with head elevated as much as possible in midaxillary line (chest tube location)
  • Cleanse skin with chlorhexidine or betadine
  • Anesthetize skin and subcutaneous tissue - raise wheal and advance/inject along superior aspect of lower rib (avoid NV bundle)
  • Make small skin nick with scalpel
  • Insert/advance needle while continuously aspirating until pleural space is entered
  • Advance catheter into pleural space while removing needle
  • Connect tubing to catheter and to evacuated container and remove desired amount of fluid
  • Obtain post-procedure CXRif:
    • Multiple needle passes required
    • Air is aspirated
    • Risk of adhesions
    • New-onset of symptoms during the procedure (chest pain, dyspnea)
    • Patient at high risk for decompensation from small pneumothorax (lung disease, positive pressure ventilation)

Complications

Ultrasound-guidance significantly reduces complication rates[2] video[3]

See Also

Pleural Effusion

References

  1. 1.0 1.1 McVay P. et al. Lack of increased bleeding after paracentesis and thoracentesis in patients with mild coagulation abnormalities. Transfusion. 1991 Feb;31(2):164-71
  2. Mercaldi CJ, Lanes SF. Ultrasound guidance decreases complications and improves the cost of care among patients undergoing thoracentesis and paracentesis. Chest. 2013;143(2):532-538. doi:10.1378/chest.12-0447
  3. 5 Minute Sono – Thoracentesis https://www.coreultrasound.com/5ms-thora/