Thoracocentesis or Thoracentesis or Chest Tube.pptx

Medical Procedure

1. Thoracocentesis By: Dr. Ayanda T. Tsabedze February 15 th , 2024

2. Presentation Outline Definition Indications Contraindications Complications Equipment Relevant Anatomy Positioning Step-by-Step Description of Procedure Aftercare Tips and Tricks References

3. What is thoracocentesis? Thoracocentesis, also known as thoracentesis, pleural tap, needle thoracostomy, or needle decompression, is a minimally invasive medical procedure to remove fluid or air from the pleural space for diagnostic or therapeutic purposes. Common reasons to have thoracocentesis done include: 1. Infection 2. Cancer 3. Symptom relief

4. Indications for Thoracocentesis Indicated for almost all patients who have pleural fluid that is new or of uncertain etiology and is ≥ 10 mm in thickness on computed tomography (CT) scan, ultrasonography, or lateral decubitus x-ray. Diagnostic thoracentesis is usually not needed when the etiology of the pleural fluid is apparent (e.g., viral pleuritis, typical heart failure). Therapeutic thoracocentesis is done to relieve symptoms in patients with dyspnea caused by a large pleural effusion

5. Contraindications to Thoracocentesis Absolute contraindications None Relative contraindications Bleeding disorder with platelets <50 000 Anticoagulation therapy with INR < 2.0 Altered chest wall anatomy Cellulitis or herpes zoster at the site of thoracentesis puncture Pulmonary disease severe enough to make life threatening complications Uncontrolled coughing or an uncooperative patient

6. Complications of Thoracentesis Major complications include: Pneumothorax Bleeding (hemoptysis due to lung puncture) Re-expansion pulmonary edema and/or hypotension Hemothorax due to damage to intercostal vessels Puncture of the spleen or liver Vasovagal syncope Bloody fluid that does not clot in a collecting tube indicates that blood in the pleural space was not iatrogenic, because free blood in the pleural space rapidly defibrinates.

7. Conditions that can cause pleural effusion Congestive heart failure. Cirrhosis Nephrotic syndrome Pulmonary hypertension. Cancer Pneumonia or lung infections (viral, bacterial or fungal). Lupus (systemic lupus erythematosus/SLE) and other autoimmune diseases. Pulmonary embolism. Pancreatitis Kidney or liver disease. Tuberculosis (TB).

8. Relevant Anatomy for Thoracentesis 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).

9. Equipment for Thoracocentesis Local anesthetic ( eg , 10 mL of 1% lidocaine), 25-gauge and 20- to 22-gauge needles, and 10-mL syringe Antiseptic solution with applicators, drapes, and gloves Thoracentesis needle and plastic catheter 3-way stopcock 30- to 50-mL syringe Wound dressing materials Bedside table for patient to lean on Appropriate containers for collection of fluid for laboratory tests Collection bags for removal of larger volumes during therapeutic thoracentesis Ultrasound machine

10. Positioning for Thoracentesis It is best done with the patient sitting upright and leaning slightly forward with arms supported. Recumbent or supine thoracentesis (e.g., in a ventilated patient) is possible but best done using ultrasonography or CT to guide procedure.

11. Step-by-Step Description of Thoracentesis 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. 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.

12. Cont’ Using a 25-gauge needle, place a wheal of local anesthetic over the insertion point. Switch to a larger (20- or 22-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.

13. Cont ’ Attach a large-bore (16- to 19-gauge) thoracentesis needle-catheter device to a 3-way stopcock, place a 30- to 50-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.

14. Cont ’

15. Cont ’ Some clinicians recommend withdrawing no more than 1.5 L in 24 hours, although there is little evidence that the risk of re-expansion pulmonary edema is directly proportional to the volume of fluid removed. Remove the catheter while patient is holding breath or expiring. Apply a sterile dressing to the insertion site.

16. Summary

17. Aftercare for Thoracocentesis

18. Pleural Effusion Analysis

19. Pleural Effusion Analysis

20. Further Diagnosis

21. Thank You

22. References 1. Feller- Kopman D, Berkowitz D, Boiselle P, et al: Large-volume thoracentesis and the risk of reexpansion pulmonary edema. Ann Thoracic Surg 84:1656–1662, 2007. 2. Hibbert RM, Atwell TD, Lekah A, et al: Safety of ultrasound-guided thoracentesis in patients with abnormal preprocedural coagulation parameters. Chest 144(2):456–463, 2013. doi : 10.1378/chest.12-2374 3. Barnes TW, Morgenthaler TI, Olson EJ, et al: Sonographically guided thoracentesis and rate of pneumothorax. J Clin Ultrasound 33(9): 1656–1661, 2005. 4. Gervais DA, Petersein A, Lee MJ, et al: US-guided thoracentesis: requirement for postprocedure chest radiography in patients who receive mechanical ventilation versus patients who breathe spontaneously. Radiology 204(2):503–506, 1997.