Thoracentesis (Emergency Medicine)

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SAMPLE EXCERPT
- Full procedure text, video and illustrations available with the full product
PRE-PROCEDURE
INDICATIONS
  • Diagnosis of pleural effusion
  • Therapeutic drainage of large effusions
  • Radiographic diagnosis of pleural effusion
    • Visible when 200 mL of fluid is present.
    • Effusions that layer on the most dependent portion of the chest (lateral decubitus view) and are at least 10 mm thick are amenable to simple thoracentesis.
CONTRAINDICATIONS
  • Coagulopathy, thrombocytopenia, or other bleeding disorders
  • Inability of the patient to cooperate
  • Abnormalities in the overlying skin
  • Mechanical ventilation
  • Hemodynamic or respiratory instability
EQUIPMENT
  • Skin cleansing agent and sterile gauze
  • Sterile drape and gloves **STERILE TECHNIQUE**
  • Local anesthetic and 5- to 10-mL syringe with 25- and 22-gauge needles
  • Needle and catheter assembly
  • 35- to 60-mL syringe for aspiration of pleural fluid
  • 3-way stopcock
  • High-pressure drainage tubing
  • Specimen tubes and evacuated containers (1 or 2)
  • Sterile occlusive dressing
  • Bedside US machine (optional)
  • Needle and catheter assemblies
    • IV catheters: 16- to 18-gauge IV catheters without retractable needles
    • Thoracentesis-specific devices
    • Through-the-needle catheters (less commonly used)
ANATOMY
  • The pleura is a thin layer of serous tissue forming the parietal and visceral pleura.
  • Pleural fluid may collect if there is excessive hydrostatic pressure, increased capillary permeability, or lymphatic obstruction.
  • The pleural cavity at the posterior costodiaphragmatic recess extends to the level of the 12th rib.
  • Needle insertion sites
    • Posterior approach (preferred)
      • The needle is inserted in the midthorax line, at least one interspace below the level of the effusion.
      • The needle should NOT BE INSERTED INFERIOR TO THE NINTH RIB. 
    • In patients unable to sit upright, a midaxillary approach may be used with the patient supine, or a posterior axillary line approach may be used with the patient in the lateral recumbent position.
  • The neurovascular bundle
    • The neurovascular bundle runs along the inferior surface of the ribs. 

PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
CARE
  • Chest films should be obtained in the following circumstances:
    • Air was aspirated during the procedure.
    • Chest pain, dyspnea, or hypoxemia develops.
    • Multiple needle passes were required.
    • The patient is critically ill or receiving mechanical ventilation.
COMPLICATIONS
  • Iatrogenic pneumothorax (see Needle Thoracostomy for further details)
  • Postexpansion pulmonary edema
    • Postexpansion pulmonary edema is rare and may occur after removal of a large volume of pleural fluid.
  • Hemothorax, intraabdominal organ injury, and air embolism
  • Pain, cough, and localized infection
RESULT ANALYSIS
  • Transudate vs. exudate
    • Transudates are caused by increased hydrostatic pressure.
    • Exudates are caused by either increased capillary permeability or lymphatic obstruction.
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