Note the depth of penetration before withdrawing the needle. Attach an 18G cannula to a syringe and advance the needle along in the same plane as the local anaesthetic was injected, ensuring that you continuously pull back on the plunger. Attach a 50ml syringe with a 3 way tap to the catheter hub and open the tap to the patient and syringe to aspirate 50ml of pleural fluid for diagnostic analysis. If performing therapeutic thoracentesis, then attach the extension set to the third port with the free end in a container to collect the pleural fluid.
Empty the syringe whilst it is still attached by pushing the plunger and re-routing the fluid down the extension set into the container. When procedure is complete remove catheter with patient at end expiration i. Consider inoculating blood culture bottles with pleural fluid if infection suspected. Consider fungal and viral studies. Monitor for evidence of any complications: pneumothorax, post expansion pulmonary oedema, bleeding, intra-abdominal organ injury rare , infection delayed and rare.
ACI Video - pleural drain insertion. NEJM video: thoracentesis procedure. Todd W. Thomsen, M. Setnik, M. Ample local anesthetic is necessary, but procedural sedation is not required in cooperative patients. Thoracentesis needle should not be inserted through infected skin eg, cellulitis or herpes zoster. If the patient is receiving anticoagulant drugs eg, warfarin , consider giving fresh frozen plasma or another reversal agent prior to the procedure.
Only unstable patients and patients at high risk of decompensation due to complications require monitoring eg, pulse oximetry, electrocardiography [ECG]. Recumbent or supine thoracentesis eg, in a ventilated patient is possible but best done using ultrasonography or CT to guide procedure.
The intercostal neurovascular bundle is located along the lower edge of each rib. Therefore, the needle must be placed over the upper edge of the rib to avoid damage to the neurovascular bundle. The liver and spleen rise during exhalation and can go as high as the 5th intercostal space on the right liver and 9th intercostal space on the left spleen.
Confirm the extent of the pleural effusion by chest percussion and consider an imaging study; bedside ultrasonography is recommended both to reduce the risk of pneumothorax and to increase the success of the procedure 2 References Thoracentesis is needle aspiration of fluid from a pleural effusion.
Select a needle insertion point in the mid-scapular line at the upper border of the rib one intercostal space below the top of the effusion. Mark the insertion point and prepare the area with a skin cleansing agent such as chlorhexidine and apply a sterile drape while wearing sterile gloves. Using a gauge needle, place a wheal of local anesthetic over the insertion point. Switch to a larger or gauge needle and inject anesthetic progressively deeper until reaching the parietal pleura, which should be infiltrated the most because it is very sensitive.
Continue advancing the needle until pleural fluid is aspirated and note the depth of the needle at which this occurs. Attach a large-bore to gauge thoracentesis needle-catheter device to a 3-way stopcock, place a to mL syringe on one port of the stopcock and attach drainage tubing to the other port. Insert the needle along the upper border of the rib while aspirating and advance it into the effusion.
When fluid or blood is aspirated, insert the catheter over the needle into the pleural space and withdraw the needle, leaving the catheter in the pleural space. While preparing to insert the catheter, cover the needle opening during inspiration to prevent entry of air into the pleural space. Withdraw 30 mL of fluid into the syringe and place the fluid in appropriate tubes and bottles for testing. If a larger amount of fluid is to be drained, turn the stopcock and allow fluid to drain into a collection bag or bottle.
Alternatively, aspirate fluid using the syringe, taking care to periodically release pressure on the plunger. Coughing is normal and represents lung re-expansion. Some clinicians recommend withdrawing no more than 1. Thus, it may be reasonable for experienced operators to completely drain effusions in one procedure in properly monitored patients. Remove the catheter while patient is holding breath or expiring. Apply a sterile dressing to the insertion site.
Advise patients to report any shortness of breath or chest pain; coughing is common after fluid removal and not a cause for concern. Undefined cookies are those that are being analyzed and have not been classified into a category as yet. Analytics analytics. Analytical cookies are used to understand how visitors interact with the website. These cookies help provide information on metrics the number of visitors, bounce rate, traffic source, etc. Advertisement advertisement.
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