Prepared by Shane Barclay MD Thoracentesis Prepared by Shane Barclay MD

Thoracentesis Objectives: Review the indications. Review the contraindications. How to perform a thoracentesis.

Indications Obtain pleural fluid to determine the cause of the effusion. Remove excess pleural fluid to assist the patient’s breathing and provide symptomatic relief.

Contraindications Uncooperative or nonconsenting patient. Local chest wall skin infection. Non correctable bleeding diathesis (platelets < 50 or INR > 2) Small effusion (difficult to tap) or bullous lung. Only one functioning lung. Severe cough or hiccups.

Technique Obtain current CXR, CBC and INR. Obtain patient consent. Position patient sitting on side of stretcher leaning on beside table (usually with arms on a pillow)

Technique 4. Using ultrasound determine the pleural fluid. 5. Insertion site should be midway between the spine and the posterior axillary line higher than the 9th intercostal space. 6. Mark the site with a skin pen. 7. Clean a large area around the insertion site. 8. Apply a sterile fenestrated drape.

Technique 9. Using a 10 cc syringe filled with local anesthetic, create a bleb on the skin. Then with the same syringe infiltrate into the skin just over the top of the rib. 10. Infiltrate and aspirate until you aspirate pleural fluid into the syringe. 11. Mark the depth of the needle it took to penetrate into the pleura.

Technique

Technique 12. With the needle still in the skin, use a #11 scalpel blade and make a small stab incision by the needle. 13. Withdraw the needle. 14. Holding the thoracentesis needle, one hand on the needle against the patient’ chest, the other on the syringe, introduce it through the incision, aspirating until you withdraw pleural fluid. 15. Pull the stylet of the needle back a centimeter or so while pushing the soft catheter into the pleural space a few centimeters.

Technique

Technique 16. Completely withdraw the stylet. 17. Reattach the 60 cc syringe and using the 2 or 3 way cock-stop, withdraw fluid for analysis or for discard. 18. Using a tubing attachment to the cock-stop, sometimes the pleural fluid will just run out into your container. Other times you may need to pull out with the syringe. 19. Once complete apply a sterile dressing to the site.

Technique

Pleural Fluid Analysis There are 2 main types of Pleural Fluid: 1. Exudate 2. Transudate

Pleural Fluid Analysis Exudate: usually from local disease processes Malignancy – Lung, breast, pleural. Infection – Pneumonia, empyema, pleuritis, viral disease Autoimmune – Rheumatoid, SLE Vascular – PTE Cardiac – Pericarditis, CABG Respiratory – Hemothorax, Chylothorax Abdominal – Subphrenic abscess

Pleural Fluid Analysis Transudate: usually from systemic disease processes Cardiac – CHF Liver – Ascites, Cirrhosis Renal – Glomerulonephritis, Nephrotic syndrome Ovarian – Meigs syndrome Autoimmune – Sarcoid Thyroid – Myxoedema

Pleural Fluid Analysis Labs to order: Cell count LDH Protein Gram stain Culture Cells for cytology Glucose pH

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