thoracocentesis

MEKELLE UNIVERSTY COLLEGE OF HEALTH SCIENSEAYDER REFERRAL HOSPITAL

LECTURE ON THORACOCENTESIS PREPARED BY

GIRMAWI MEBRAHTOM C II

25/1/06E.C

Thoracocentesis

Prepared by Girmawi.M C II

content

DefinitionIndicationContraindications Techniques/procedure/MaterialsComplication

INTRODUCTION• Thoracentesis is a percutaneous procedure during which a

needle is inserted into the pleural space and pleural fluid is removed.

• Thoracocentesis 1-Diagnstic : refers to removal of a small volume of

pleural fluid for analysis. 2-Threaputic : refers to removal of a large volume of

pleural fluid for relief of symptoms.

INDICATION Thoracentesis is indicated for the symptomatic treatment of

large pleural effusions

pleural effusions of any size that require diagnostic analysis.

To determine the nature of the effusion (i.e., transudate, exudate)

To identify potential causes malignancy, infection).

Cont’d There are two circumstances in which diagnostic

thoracentesis is usually not required: -when there is a small amount of pleural fluid and -a secure clinical diagnosis (e.g viral pleurisy) or - when there is clinically obvious heart failure (HF)

without atypical features

Cont’d Atypical features that should prompt consideration of

diagnostic thoracentesis in a patient with HF include -A unilateral effusion, especially if it is left-sided -Bilateral effusions that are of disparate sizes -Pleurisy -Fever -Normal cardiac silhouette on chest radiograph -An echocardiogram that is inconsistent with heart failure -B-type brain natriuretic peptide (BNP) levels that are

inconsistent with heart failure -An alveolar-arterial oxygen gradient that is larger than

expected -The effusion does not resolve with heart failure therapy

CONTRAINDICATION There are no absolute contraindications for thoracentesis.

Relative contraindications include the following:

Uncorrected bleeding diathesis Chest wall cellulitis at the site of puncture

A very small volume of pleural fluid, with less than 1 cm distance from the pleural fluid line to the chest wall on a decubitus chest radiograph.

Periprocedural care

• Patient education

• Informed consent

EQUIPMENT Several commercially available medical devices are

specifically designed for performing thoracentesis. Such devices include the following:

Arrow-Clarke Thoracentesis Device (Teleflex Medical, Research Triangle Park, NC)

Argyle Turkel Safety Thoracentesis System (Covidien, Mansfield, MA)

Critical CarIf a commercial use-specific device is not available, all of the necessary equipment can be obtained from the supplies located in most inpatient settings, critical care units (CCUs), or emergency departments (Eds)

Cont’d

Cont’d

Cont’d• Thoracentesis device - This typically consists of an 8-French

catheter over an 18-gauge, 7.5-in. (19-cm) needle with a 3-way stopcock and, ideally, a self-sealing valve

• Self-assembled device, if a thoracentesis device is unavailable - Options include using an 18-gauge needle or a 12-gauge intravenous (IV) catheter connected to a 60-mL syringe and then to a stopcock after the needle is removed from the 60-mL syringe

• Injection needle – 22 gauge, 1.5 in. (3.81 cm) • Injection needle – 25 gauge, 1 in. (2.54 cm)• Luer-Lok syringe - 10 mL• Luer-Lok syringe - 5 mL• Luer-Lok syringe - 60 mL • Tubing set with aspiration/discharge device • Antiseptic - Chlorhexidine solution [Hibiclens] is preferred• Lidocaine - 1% or 2% solution, 10-mL ampule

Cont’d• Specimen cap for 60-mL syringe • Specimen vials or blood tubes• Drainage bag or vacuum bottle• Drape - 24 × 30 in., with 4-in. fenestration with adhesive strip • Sterile towels• Scalpel - No. 11 blade • Adhesive dressing - 7.6 × 2.5 cm • Gauze pad(s) - 4 × 4 in.

PATIENT PREPARATION• Patient preparation includes adequate Anesthesia proper positioning Anesthesia local anesthesia : lidocaine The skin subcutaneous tissue should all be rib periostem well infiltrated

with intercostal muscle and local anesthesia partial pleura (lidocaine)

Cont’d Positioning Patients who are alert and cooperative are most comfortable in a

Seated position Leaning slightly forward Resting the head on the arms or hands on a pillow.

Unstable patients and those who are unable to sit up may be supine for the procedure

The patient is moved the extreme side of the bed,

The ipsilateral hand is placed behind the head and a towel roll is placed under the contra lateral shoulder.

Needle Insertion Site• Needle over the upper edge of the rib

TECHNIQUE

① Selection of puncture site Guided by Ultrasound or Physical examination

Ultrasound guidance is definitely indicated for patients with loculated effusions. Physical examination is used to guide selection of puncture site when 1-For patients with a nonloculated, free-flowing effusion. 2- when ultrasound is not available

Cont’d The following landmarks are employed In P.Examination 1- One to two interspaces below the level at which breath sounds decrease or disappear percussion becomes dull, and fremitus disappears

2- Above the ninth rib, to avoid sub diaphragmatic puncture

3-Midway between the spine and the posterior axillary line, because the ribs are easily palpated in this location.

• When performing a thoracentesis on an elderly patient, it is prudent to choose a puncture site 9 to 10 cm lateral to the spine, assuming that the fluid collection will be equally accessible.

② A wide area surrounding the puncture site should be sterilized with

- 0.05 percent chlorhexidine or - 10 percent povidone-iodine solution

③ A sterile drape is placed over the puncture site and sterile towels are used to establish a large sterile field within which to work

④ The skin, subcutaneous tissue, rib periosteum, intercostal muscles, and parietal pleura should be well infiltrated with anesthetic (lidocaine 1-2%)

The epidermis is initially infiltrated with anesthetic using a syringe and 25-gauge needle. Next, a syringe with a 22-gauge needle is inserted, advanced toward the rib, and then "walked" over the superior edge of the rib

.

Cont’d

• As the needle is advanced, aspiration should be attempted by intermittently pulling back on the plunger of the syringe.

• Anesthetic is injected if there is no return of blood or pleural fluid into the syringe.

• Intermittent aspiration serves two purposes. 1-blood return indicates that the needle is intravascular and prevents the operator from injecting anesthetic intravascularly.

2- pleural fluid return indicates that the needle has entered the pleural space.

Cont’d

• If a commercially available device or a large intravenous catheter is being used, the skin should be nicked with a No. 11 scalpel blade to reduce drag as the catheter is advanced through the skin.

Cont’d• With either a syringe pump or a vacuum bottle, the pleural

effusion is drained until the desired volume has been removed for symptomatic relief or diagnostic analysis.

Cont’d• Approximately 30 to 75 mL of pleural fluid should be

withdrawn for analysis, and then the needle removed.

• A "dry" thoracentesis may result from Absence of pleural fluid, Incorrect needle placement, Thick pleural fluid, Use of an inappropriately short needle

Cont’do Aspiration of air implies that the lung has been punctured because

the needle was inserted superior to the effusion or too deeply

o Aspiration of a small amount of blood suggests that the needle may have been inserted inferior to the effusion (ie, subdiaphragmatically)

o Failure to aspirate anything implies that the needle may have been too short to penetrate the pleura, especially in an obese patient.

COMPLICATION

Complication Major Complication Minor Complication

Major complications

• Pneumothorax (11%• Hemothorax (0.8%) • Laceration of the liver or spleen (0.8%) • Diaphragmatic injury • Empyema• Tumor seeding

Minor complications

• Pain (22%)• Dry tap (13%) • Cough (11%) • Subcutaneous hematoma (2%) • Subcutaneous seroma (0.8%) • Vasovagal syncope

THANK YOU