Thoracentesis

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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/