Thoracentesis: Difference between revisions

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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==
#Plt <50K
{{Thoracentesis with coagulopathy}}
#INR >2x normal
#Mechanical ventilation


==Equipment Needed==
==Equipment Needed==
#Thoracentesis kit
*Thoracentesis kit
#Sterile gloves
*Sterile gloves
#Chlorhexidine scrub
*Chlorhexidine or betadine scrub
#Evacuated container
*Evacuated container
*[[Ultrasound]]


#Labs
==Procedure==
##Protein, gluc, LDH, gram stain, culture, cell count, amylase, pH, TB, fungal, cytology
[[File:Gray530.png|thumb|Left pleura cavity (viewed from left) showing intercostal bundles (vein, artery, and nerve) under ribs.]]
##Send serum LDH, protein at same time
*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


==Procedure==
*Obtain post-procedure CXRif:
#Choose insertion site/positioning
**Multiple needle passes required
##Upright position in mid-scapular or posterior axillary line (usual technique)
**Air is aspirated
##Lateral decubitus position w/ fluid side down in post axillary line (if cannot sit up)
**Risk of adhesions
##Supine w/ head elevated as much as possible in midaxillary line (chest tube location)
**New-onset of symptoms during the procedure (chest pain, dyspnea)
#Prep skin
**Patient at high risk for decompensation from small pneumothorax (lung disease, positive pressure ventilation)
#Anesthetize skin
##Raise wheal and advance/inject along superior aspect of lower rib (avoid NV bundle)
#Puncture skin w/ scalpel (optional)
#Insert/advance catheter while continuously aspirating until pleural space is entered
#Drain fluid
#Post-procedure CXR only necessary if:
##Multiple needle passes required
##Air is aspirated
##Risk of adhesions
##New-onset of symptoms during the procedure (chest pain, dyspnea)
##pts at high risk for decompensation from small ptx (lung dz, mechanical ventilation)


==Complications==
==Complications==
#Pneumothorax
''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>
#Cough (9%)
*[[Pneumothorax]] (4-19%)
#Unilateral pulmonary edema
*Cough (9%)
#Reexpansion pulmonary edema
*Infection (2%)
#Transient hypoxia from V-Q mismatch
*[[Hemothorax]]
#Hemothorax
*[[Splenic injury]]
#Infection (2%)
*[[Diaphragmatic injury]]
#Hemoperitoneum
*[[Hepatic injury]]
*[[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, p.145 (130-147)
<references/>


[[Category:Procedures]]
[[Category:Procedures]]
[[Category:Pulm]]
[[Category:Pulmonary]]

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/
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