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thoracentesis (pleuracentesis, pleurocentesis, pleural tap, transthoracic needle aspiration ,thoracocentesis)

transthoracic needle aspiration Indications: 1) pleural effusion of undetermined origin 2) therapeutic: a) for improving pulmonary status b) contralateral mediastinal shift 3) small pneumothoraces Contraindications: 1) hemorrhagic disorder* 2) active local infection over the area of access * ultrasound-guided thoracentesis can be done safely even in patients on anticoagulants or antiplatelet agents [10] Procedure: preparation: see Radiology: precautions: 1) always approach from the top of the rib - vessels and nerves run along inferior aspect of ribs 2) a clamp placed on the needle may prevent overpenetration 3) be prepared for pneumothorax 4) bedside ultrasound recommended [6] procedure 1) position patient on the edge of bed with arms supported by a table 2) percuss the effusion to the highest & lowest levels 3) determine point of access 4) choose an access above the 8th rib, as low in the effusion as possible 5) mark the spot to indent the skin 6) prepare the skin with disinfectant 7) anesthetize with lidocaine 1%, locally a) make a wheal using a 25 gauge needle b) anesthetize the periosteum of the rib, walking the needle superiorly c) advance the needle into the pleural cavity & aspirate to confirm fluid or air & note depth of needle 8) place clamp on intracath needle at the depth noted in 7c 9) enter pleural cavity with intracath at top of rib & confirm fluid or air 10) advance catheter through needle 11) aspirate fluid, not more than 1.5 liters 12) remove the catheter as a unit 13) do not pull the catheter back through the needle 14) cover insertion with bandage * video with ultrasound guidance [9] Laboratory: - preprocedural - platelet count > 50,000/uL - international normalized ratio (INR) < 2.0 [8] - can be performed safely under ultrasound guidance with INR < 3.5 & platelet count > 20,000/uL [7] - pleural fluid analysis: (see pleural effusion) - Useful studies in pleural fluid analysis include: - Gram's stain, cell count & differential, amylase, triglycerides, microbiologic stains, cultures, cytology, LDH, glucose, protein - priming the fluid collection bag with 300-1000 U of heparin & submitting a large volume of pleural fluid may increase diagnostic yield; a) for direct smear/cytospin & cell block preparations, >= 150 mL is recommended b) for direct smear/cytospin only, 60 mL is adequate [4] Radiology: 1) obtain PA, lateral & decubitus radiographs - thoracentesis can be safely performed on effusions demonstrating a thickness of 1 cm on lateral decubitus radiograph in the absence of hemostasis disorders. 2) loculated effusions may be localized with ultrasound or CT - US reduces the risk of pneumothorax [5] Complications: 1) pneumothorax 2) hemothorax 3) re-expansion pulmonary edema 4) intrapulmonary hemorrhage 5) hemoptysis 6) vagal inhibition 7) air embolism 8) subcutaneous emphysema 9) bronchopleural fistula 10) empyema 11) puncture of liver or spleen Management: Follow-up: 1) chest X-ray 2) pain relief as needed 3) oxygen for post-thoracentesis hypoxia - secondary to ventilation perfusion mismatch after lung expansion

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pleural effusion

General

clinical procedure

References

  1. Manual of Medical Therapeutics, 28th edition, Ewald & McKenzie (eds) Little, Brown & Co, 1995, pg 166-167, 259
  2. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 773
  3. Journal Watch 22(6):46, 2002 Fartoukh M et al Clinically documented pleural effusions in medical ICU patients: how useful is routine thoracentesis? Chest 121:178, 2002 PMID: 11796448
  4. Swiderek J et al Prospective study to determine the volume of pleural fluid required to diagnose malignancy. Chest 2010 Jan; 137:68 PMID: 19741064
  5. Gordon CE et al Pneumothorax following thoracentesis: A systematic review and meta-analysis. Arch Intern Med 2010 Feb 22; 170:332 PMID: 20177035
  6. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018.
  7. Hibbert RM et al. Safety of ultrasound-guided thoracentesis in patients with abnormal preprocedural coagulation parameters. Chest 2013 Aug; 144:456 PMID: 23493971
  8. Patel IJ et al Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous Image-guided Interventions. Journal of Vascular and Interventional Radiology.2012 23:727 http://www.jvir.org/article/S1051-0443(12)00297-7/abstract
  9. Peris A, Tutino L, Cianchi G, Gensini G. Videos in Clinical Medicine. Ultrasound Guidance for Pleural-Catheter Placement. N Engl J Med 2018; 378:e19. April 5, 2018 PMID: 29617577 http://www.nejm.org/doi/full/10.1056/NEJMvcm1102920
  10. Patel PP, Singh S, Atwell TD et al. The safety of ultrasound-guided thoracentesis in patients on novel oral anticoagulants and clopidogrel: A single-center experience. Mayo Clin Proc 2019 Aug; 94:1535-1541. PMID: 31303429 https://www.mayoclinicproceedings.org/article/S0025-6196(19)30218-6/fulltext