Thoracentesis

Revision as of 20:06, 13 May 2015 by Rossdonaldson1 (talk | contribs) (Labs)

Indications

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

Relative Contraindications

Thoracentesis if coagulopathic

  • Platelets <50K[1]
  • INR >2x normal[1]
  • Mechanical ventilation

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
  • 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