Difference between revisions of "Thoracentesis"

(Source)
Line 3: Line 3:
 
*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==
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**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
+
*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)
+
**Pt at high risk for decompensation from small ptx (lung disease, positive pressure ventilation)
  
 
==Complications==
 
==Complications==

Revision as of 07:15, 6 September 2015

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

  • 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)
  • 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)
    • Pt at high risk for decompensation from small ptx (lung disease, positive pressure ventilation)

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

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