Difference between revisions of "Thoracentesis"

(Equipment Needed)
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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==
 
==Relative Contraindications==
#Plt <50K
+
*Plt <50K
#INR >2x normal
+
*INR >2x normal
#Mechanical ventilation
+
*Mechanical ventilation
  
 
See also [[Procedures in Patients with Coagulopathies]]
 
See also [[Procedures in Patients with Coagulopathies]]
  
 
==Equipment Needed==
 
==Equipment Needed==
#Thoracentesis kit
+
*Thoracentesis kit
#Sterile gloves
+
*Sterile gloves
#Chlorhexidine scrub
+
*Chlorhexidine scrub
#Evacuated container
+
*Evacuated container
#Ultrasound
+
*Ultrasound
  
 
===Labs===
 
===Labs===
##Protein, gluc, LDH, gram stain, culture (blood cx bottle), cell count, amylase, pH, TB (adenosine deaminase), fungal, cytology
+
**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
+
**Send serum LDH, protein at same time
  
 
==Procedure==
 
==Procedure==
#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 w/ 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 w/ head elevated as much as possible in midaxillary line (chest tube location)
#Prep skin
+
*Prep skin
#Anesthetize skin
+
*Anesthetize skin
##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)
#Puncture skin w/ scalpel (optional)
+
*Puncture skin w/ scalpel (optional)
#Insert/advance catheter while continuously aspirating until pleural space is entered
+
*Insert/advance catheter while continuously aspirating until pleural space is entered
#Drain fluid
+
*Drain fluid
#Post-procedure CXR only necessary if:
+
*Post-procedure CXR only necessary if:
##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)
+
**pts at high risk for decompensation from small ptx (lung dz, on ventilator)
  
 
==Complications==
 
==Complications==
#Pneumothorax (4-19%)
+
*Pneumothorax (4-19%)
#Cough (9%)
+
*Cough (9%)
#Infection (2%)
+
*Infection (2%)
#Hemothorax
+
*Hemothorax
#Splenic rupture
+
*Splenic rupture
#Reexpansion pulmonary edema
+
*Reexpansion pulmonary edema
##Dyspnea, tachypnea, cough, frothy sputum
+
**Dyspnea, tachypnea, cough, frothy sputum
##Tx with aggressive volume resuscitation
+
**Tx with aggressive volume resuscitation
  
 
==See Also==
 
==See Also==

Revision as of 20:05, 13 May 2015

Indications

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

Relative Contraindications

  • Plt <50K
  • INR >2x normal
  • Mechanical ventilation

See also Procedures in Patients with Coagulopathies

Equipment Needed

  • Thoracentesis kit
  • Sterile gloves
  • Chlorhexidine scrub
  • Evacuated container
  • 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

  • Choose insertion site/positioning
    • 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)
    • Supine w/ head elevated as much as possible in midaxillary line (chest tube location)
  • Prep skin
  • 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, on ventilator)

Complications

  • Pneumothorax (4-19%)
  • Cough (9%)
  • Infection (2%)
  • Hemothorax
  • Splenic rupture
  • Reexpansion pulmonary edema
    • Dyspnea, tachypnea, cough, frothy sputum
    • Tx with aggressive volume resuscitation

See Also

Pleural Effusion

Source

  • Robert and Hedges
  • Tintinalli