Thoracentesis

Indications

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

Contraindications

Thoracentesis if coagulopathic

• Platelets <50K
• INR >2x normal
• 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 CXR if:
  • 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 video

• Pneumothorax (4-19%)
• Cough (9%)
• Infection (2%)
• Hemothorax
• Splenic injury
• Diaphragmatic injury
• 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

Pleural Effusion

External Links

Videos

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