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1. Removal of fluid from the pleural space for diagnostic or therapeutic purposes
1. Local skin infection over proposed site of thoracentesis
2. Uncontrolled bleeding or clotting abnormality
1. 1% or 2% lidocaine with epinephrine for local anesthesia
2. 3 ml syringe with 1 1/2” 25-gauge needle for anesthetic infiltration
3. 1 1/2 “ 18-gauge needle
4. Skin prep solution, sterile drapes
5. 2- 1-litre evacuated bottles for fluid collection
6. Thoracentesis or blood set tubing (these are short IV tubings with a midpoint clamp, a fastened needle at one end, and a port for a second needle at the other end) NOTE: A secondary IV tubing set may also be used
7. Occlusive dressing
8. Universal precautions materials
Optional: 60-ml syringe with 3-way stopcock
Preprocedure patient education
1. Obtain informed consent
2. Inform patient of the possibility of major complications and their treatment
3. Explain the major steps of the procedure
4. Explain the necessity of positioning, and follow-up chest radiograph
1. Assess indications for procedure and obtain informed consent as appropriate. Use universal precautions and sterile technique.
2. Obtain a chest radiograph to document and localize effusion. Perform a physical examination to define the place where you will enter the thorax. Clinical findings associated with an effusion include diminished breath sounds at the base(s) of the affected lung(s), and a decreased percussion note.
3. Position patient upright and sitting with arms up and forward (draping arms over a bedside table is perfect). See Figure 1.
Figure 1: Positioning the patient
4. Select site for needle puncture. This should be done clinically, by percussion of the chest wall, to locate the upper end of the effusion. Measure down two rib interspaces from this upper end of the effusion in the mid-scapular line. Mark this space with a pen or fingernail; this will be the needle puncture site.
5. Cleanse skin over puncture site with skin prep and drape to create a sterile field.
6. Anesthetize the skin and deeper layers with the lidocaine. Be sure to anesthetize the pleura, which is quite pain-sensitive. If lidocaine enters the pleural space, it will simply mix with the effusion and be of little concern.
7. Remove thoracentesis or blood tubing from its packaging, and close the midpoint clamp securely. Attach the 18-gauge needle to the free end of the tubing.
8. Remove the protective covering from the evacuated bottle stopper. Insert the tubing with the fixed needle through the stopper.
9. With the free 18-gauge needle, puncture the skin at the marked intercostal space. Advance the needle until you feel a slight give (entering the pleural space).
10. Open the clamp. This will provide negative pressure from the evacuated bottle. If you are in the right location, fluid will drain spontaneously into the bottle. If no fluid flows, you may advance the needle cautiously until the fluid flow begins.
11. If frank blood returns, you may have punctured the lung. Withdraw needle slowly until fluid flows. If no fluid flows at all, with draw the needle until it is just under the skin. Clamp the tubing, and with draw the needle completely from the patient. Re-examine the patient to correlate the location of the effusion, and repeat steps 5-10.
To change collection bottle:
12. Close clamp on collection tubing. Leave intercostal needle in place. Remove needle from the full collection bottle, and replace it into the new empty collection bottle. Then, re-open clamp.
When procedure is done:
13. Leave tubing clamp OPEN. Remove intercostal needle slowly and completely from patient. Dress puncture site with an occlusive dressing. Leaving the collection tubing clamp open maintains a negative pressure throughout the system and in the pleural space, minimizing the chance of an iatrogenic pneumothorax.
14. Obtain a post-procedure radiograph to check for iatrogenic pneumothorax.
Alternate technique using a 3-way stopcock:
1. Follow Steps 1-6 above. Attach the free end of the collection tubing to the 3-way stopcock, and attach the collection syringe and the 18-gauge needle to the other stopcock ports. Familiarize yourself with the operation of the stopcock. Make sure the stopcock is in the OFF position in the direction of the collection tubing.
2. Puncture the collection bottle with the 18-gauge needle, and CLOSE the stopcock connection to the collection bottle.
3. Now puncture the skin over the selected intercostal space and advance into the pleural space.
4. Withdraw the syringe plunger to fill the syringe with pleural fluid.
5. Turn stopcock OFF in the direction of the collection tubing. This will open up the connection between the syringe and the collection bottle. Empty the syringe into the collection bottle, then CLOSE the connection to the collection bottle.
6. Repeat Steps 4 and 5 until desired amount of fluid is withdrawn.
7. Remove intercostal needle while maintaining slight negative pressure on the syringe.
8. Obtain post-procedure radiograph to check for iatrogenic pneumothorax.
Complications, Prevention, and Management
Prevention and Management
Fluid doesn’t flow
Reposition needle by either advancing or withdrawing slightly
May have to chose another interspace
Check tubing connections and collection bottle for vacuum
Fluid is bloody
May have punctured lung...withdraw or reposition needle
Could this be an underlying hemothorax?
Patient is coughing during procedure
Needle may be touching pleura of lung…withdraw slightly so that cough stops yet fluid still flows
Have patient only take shallow breaths during procedure
Decreased breath sounds in hemithorax after procedure
Possible pneumothorax. Obtain chest radiograph. If greater than 10% pneumothorax, will need to insert a chest tube
Documentation in the medical record
1. Consent if obtained
2. Indications or contraindications for the procedure on this patient
3. Procedural technique, including examination of the chest before and after the procedure, radiographic findings before and after the procedure, and amount of fluid removed
4. Any complications
5. Who was notified about the complication (attending physician, family, etc)
6. If pneumothorax resulted from procedure, approximate percentage of collapse, and requirement for a chest tube
Items for evaluation of person learning this procedure
1. Anatomy of chest wall and underlying lung
2. Indications for this procedure
3. Contraindications for this procedure
4. Interactions between physician, and the patient and/or family
5. Use of sterile technique and universal precautions
6. Technical ability
7. Appropriate documentation
8. Understanding of potential complications and their correction
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