Difference between revisions of "Thoracentesis"

(Created page with "==Indications== Insert ==Contraindications== Insert ==Equipment Needed== Insert ==Procedure== Insert ==Complications== -pneumothorax -cough (9%) -uni...")
 
 
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==Indications==
 
==Indications==
 
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*New-onset pleural effusion (except obvious [[CHF]]-induced effusion)
 
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*Symptomatic pleural effusion
Insert
 
 
 
 
  
 
==Contraindications==
 
==Contraindications==
 
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{{Thoracentesis with coagulopathy}}
 
 
Insert
 
 
 
 
  
 
==Equipment Needed==
 
==Equipment Needed==
 
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*Thoracentesis kit
 
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*Sterile gloves
Insert
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*Chlorhexidine or betadine scrub
 
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*Evacuated container
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*[[Ultrasound]]
  
 
==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
 +
**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
  
 
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*Obtain post-procedure CXRif:
Insert
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**Multiple needle passes required
 
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**Air is aspirated
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**Risk of adhesions
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**New-onset of symptoms during the procedure (chest pain, dyspnea)
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**Patient at high risk for decompensation from small pneumothorax (lung disease, positive pressure ventilation)
  
 
==Complications==
 
==Complications==
 
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''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>
 
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*[[Pneumothorax]] (4-19%)
-pneumothorax
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*Cough (9%)
 
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*Infection (2%)
-cough (9%)
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*[[Hemothorax]]
 
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*[[Splenic injury]]
-unilateral pulmonary edema
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*[[Diaphragmatic injury]]
 
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*[[Hepatic injury]]
-reexpansion hypotension
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*[[Vascular injury]]/bleeding
 
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*[[Air embolism]]
-transient hypoxia from V-Q mismatch
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*Reexpansion [[pulmonary edema]]
 
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**Treatment should include supportive care with [[noninvasive ventilation]] as needed
-hemothorax
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**Diuresis is not a primary treatment for reexpansion pulmonary edema
 
 
-infection (2%)
 
 
 
-hemoperitoneum
 
 
 
 
  
 
==See Also==
 
==See Also==
 +
[[Pleural Effusion]]
  
 
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==References==
Insert
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<references/>
 
 
 
 
 
==Source==
 
 
 
 
 
Robert and Hedges, p.145 (130-147)
 
 
 
 
 
 
 
  
 
[[Category:Procedures]]
 
[[Category:Procedures]]
 +
[[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/