THORACENTESIS

Thoracentesis (from Greek, thorax + centesis, puncture) also known

as thoracocentesis or pleural tap, is an invasive procedure to remove fluid or air from the pleural space for diagnostic or therapeutic purposes. A cannula, or hollow needle, is carefully introduced into the thorax, generally after administration of local anesthesia. The procedure was first described in 1852. The recommended location varies depending upon the source. It is critical that the patient hold his or her breath to avoid piercing of the lung. Some sources recommend the midaxillary line, in the sixth, seventh, or eighth intercostal space. Whenever possible, the procedure should be performed under ultrasound guidance, which has shown to reduce complications. Background Thoracentesis (thoracocentesis) is a core procedural skill for hospitalists, critical care physicians, and emergency physicians. With proper training in both thoracentesis itself and the use of bedside ultrasonography, providers can perform this procedure safely and successfully. Before the procedure, bedside ultrasonography can be used to determine the presence and size of pleural effusions and to look for loculations. During the procedure, it can be used in real time to facilitate anesthesia and then guide needle placement. Indications: This procedure is indicated when unexplained fluid accumulates in the chest cavity outside the lung. In more than 90% of cases analysis of pleural fluid yields clinically useful information. If a large amount of fluid is present, then this procedure can also be used therapeutically to remove that fluid and improve patient comfort and lung function.

cancer, congestive heart failure, pneumonia, and recentsurgery tuberculosis

pneumothorax, fluid (pleural fluid) or blood (hemothorax)

tube thoracostomy

Contraindications

coagulation disorder Relative contraindications include bullous disease (e.g.emphysema), use of positive end-expiratory pressure (PEEP) and, only one functioning lung (due to diminished reserve).

The aspiration should not exceed 1L as there is a risk of development of pulmonary edema.

Periprocedural Care: Patient Education/Informed Consent,

Consent should be obtained from the patient or family member. The reason the procedure is being performed (suspected diagnosis); the risk, benefits, and alternatives of the procedure; the risks and benefits of the alternative procedure; and the risk and benefits of not undergoing the procedure.

Discuss how these risks can be avoided or prevented (eg, proper positioning, ensuring that the patient remains as still as possible during the procedure, adequate analgesia).

Equipment Several commercially available medical devices are specifically designed for performing thoracentesis. Such devices include the following: Arrow-Clarke Thoracentesis Device (Teleflex Medical, Research Triangle Park, NC) Argyle Turkel Safety Thoracentesis System (Covidien, Mansfield, MA) Critical Care Thoracentesis Set (Cook Medical, Bloomington, IN) If a commercial use-specific device is not available, all of the necessary equipment can be obtained from the supplies located in most inpatient settings, critical care units (CCUs), or emergency departments (EDs). Thoracentesis device - This typically consists of an 8-French catheter over an 18-gauge, 7.5in. (19-cm) needle with a 3-way stopcock and, ideally, a self-sealing valve Self-assembled device, if a thoracentesis device is unavailable - Options include using an 18-gauge needle or a 12-gauge intravenous (IV) catheter connected to a 60-mL syringe and then to a stopcock after the needle is removed from the 60-mL syringe Injection needle 22 gauge, 1.5 in. (3.81 cm) Injection needle 25 gauge, 1 in. (2.54 cm) Luer-Lok syringe - 10 mL Luer-Lok syringe - 5 mL Luer-Lok syringe - 60 mL Tubing set with aspiration/discharge device Antiseptic - Chlorhexidine solution [Hibiclens] is preferred Lidocaine - 1% or 2% solution, 10-mL ampule

 Specimen cap for 60-mL syringe Specimen vials or blood tubes Drainage bag or vacuum bottle Drape - 24 30 in., with 4-in. fenestration with adhesive strip Sterile towels Scalpel - No. 11 blade Adhesive dressing - 7.6 2.5 cm Gauze pad(s) - 4 4 in.

Patient Preparation Patient preparation includes adequate anesthesia and proper positioning. Anesthesia

In addition to local anesthesia, mild sedation may also be considered. IV midazolam or lorazepam can attenuate the anxiety that may be associated with any invasive procedure. Analgesia is critically important, in that pain is the most common complication of thoracentesis. Local anesthesia is achieved with generous local infiltration of lidocaine.

The skin, subcutaneous tissue, rib periosteum, intercostal muscle, and parietal pleura should all be well infiltrated with local anesthetic. It is particularly important to anesthetize the deep part of the intercostal muscle and the parietal pleura because puncture of these tissues generates the most pain. Pleural fluid is often obtained via aspiration during anesthetic infiltration of these deeper structures; this helps confirm proper needle location.

Positioning Patients who are alert and cooperative are most comfortable in a seated position (see the image below), leaning slightly forward and resting the head on the arms or hands or on a pillow, which is placed on an adjustable bedside table. This position facilitates access to the posterior axillary space, which is the most dependent part of the thorax. Unstable patients and those who are unable to sit up may be supine for the procedure. One option for proper positioning of patient. Easy access to the 7-9 rib space along the posterior axillary line.

The patient is moved to the extreme side of the bed, the ipsilateral hand is placed behind the head, and a towel roll is placed under the contralateral shoulder. This measure facilitates dependent drainage and provides good access to the posterior axillary space.

Technique Approach Considerations: Proper personnel resources should be ensured, appropriate equipment collected, and diagnostic laboratory studies preordered, as necessary. The clinician should become comfortable with the equipment available at the facility. If necessary, an unused kit or one from an aborted procedure may be opened to permit evaluation of the components. The clinician should likewise become comfortable with the ultrasound machine and learn how to adjust key functions such as depth and overall gain. Anxiolysis should be considered and good local analgesia provided. Thoracentesis can be fraught with patient anxiety, and pain is the most common complication. If mild sedation is being considered, intravenous (IV) medications should be administered to the patient in advance. The patient should be positioned appropriately. Thoracentesis can be performed with the patient sitting upright and leaning over a Mayo stand or with the patient supine (via an axillary approach). Thoracentesis (Thoracocentesis) Thoracentesis is performed as follows. Bedside ultrasonography After the patient has been positioned, ultrasonography is performed to confirm the pleural effusion, assess its size, look for loculations, and determine the optimal puncture site. Either a curvilinear transducer (2-5 MHz) or a high-frequency linear transducer (7.5-1 MHz) may be used (see the image below). The diaphragm is brightly echogenic and should be clearly identified. Its exact location throughout the respiratory cycle should be determined. It is important to select a rib interspace into which the diaphragm does not rise up at endexhalation. USG image using curvilinear probe.Image shows chest wall and large volume of pleural fluid.

 Motion-mode (M-mode) ultrasonography can also be used to determine the depth of the lung and the amount of fluid between the chest wall and the visceral pleura (see the image below). Freely floating lung can be seen as wavelike undulations on the M-mode tracing. Ultrasound image in M-mode showing sinusoidal wave pattern. This is created by the lung moving within the large pleural effusion during respiration. The depth of the lung and the amount of fluid between the parietal pleura (adherent to the chest wall) and visceral pleura (adherent to lung tissue) are easily measured with ultrasonography. Bedside ultrasonography is a useful guide for thoracentesis: It can determine the optimal puncture site, improve the administration of local anesthetics, and, most important, minimize the complications of the procedure.[2] The optimal puncture site may be determined by searching for the largest pocket of fluid superficial to the lung and by identifying the respiratory path of the diaphragm (see the video below). Traditionally, this is between the 7th and 9th rib spaces and between the posterior axillary line and the midline. Bedside ultrasonography can confirm the optimal puncture site, which is then marked. Video clip of ultrasound using the linear probe. Image demonstrates 2 ribs with their associated acoustic shadows, rib interspace, pleural fluid, and the presence of the diaphragm rising up into this rib interspace. Preparation of puncture site Standard aseptic technique is used for the remaining steps of the procedure. Sterile probe covers are available and should be used if thoracentesis is performed under real-time ultrasonographic guidance. A wide area is cleaned with an antiseptic bacteriostatic solution.[6] Chlorhexidine solution is preferred for preparing the skin (see the image below); it dries faster and is far more effective than povidone-iodine solution. Application of chlorhexidine solution. A sterile drape is placed over the puncture site (see the first image below), and sterile towels are used to establish a large sterile field within which to work (see the second image below). Sterile drape with fenestration and adhesive strip placed over puncture site, with sterile towels draping a large work area. Sterile towels on the bed, creating a large sterile work space.

 If the patient has loose skin or significant subcutaneous tissue, the puncture site can be optimized by using 3-in. tape to pull the skin or subcutaneous tissue out of the way before marking the spot and cleaning the puncture site. The skin, subcutaneous tissue, rib periosteum, intercostal muscles, and parietal pleura should be well infiltrated with anesthetic (lidocaine 1-2%) (see the image below). Infiltration can also be guided by real-time ultrasonography using a high-frequency linear transducer (7.5-10 MHz). Administering anesthesia to the skin, subcutaneous tissue, rib periosteum, intercostal muscle, and parietal pleura. Insertion of device or catheter and drainage of effusion If a commercially available device or a large intravenous catheter is being used, the skin should be nicked with a No. 11 scalpel blade to reduce drag as the catheter is advanced through the skin (see the image below). Nicking the skin with scalpel to reduce skin drag as the catheter is advanced through the skin. With aspiration initiated, the device is advanced over the superior aspect of the rib until pleural fluid is obtained (see the image below). The neurovascular bundle is located at the inferior border of the rib and should be avoided. Advancing the device over the superior aspect of the rib. Most commercial devices have a marker at 5 cm (see the image below). At this depth, the hemithorax is usually entered, and the needle need not need be advanced any further. The 5-cm mark is at the level of the skin. The catheter is then fed over the needle introducer (see the first image below). In most cases, it can be fed all the way to the hub (see the second image below). Feeding the catheter over the needle introducer. The catheter is fed all the way to the hub. With either a syringe pump or a vacuum bottle, the pleural effusion is drained until the desired volume has been removed for symptomatic relief or diagnostic analysis (see the image below). Use the manual syringe pump method or a vacuum bottle. The syringe pump method (shown here) is more labor intensive and can cause thumb neurapraxia in the operator. Completion of procedure The catheter or needle is carefully removed, and the wound is dressed. If there is any doubt, pleural fluid should be sent for diagnostic analysis (see below); in practice, diagnostic

analysis is almost always necessary.The patient is repositioned as appropriate for his or her comfort and respiratory status. Finally, a procedure note is written, commenting specifically on the descriptive characteristics of the pleural fluid. Diagnostic Analysis of Pleural Fluid Pleural fluid is labeled and sent for diagnostic analysis. If the effusion is small and contains a large amount of blood, the fluid should be placed in a blood tube with anticoagulant so that it does not clot. The following laboratory tests should be requested: pH level Gram stain, culture Cell count and differential Glucose level, protein levels, and lactic acid dehydrogenase (LDH) level Cytology Creatinine level if urinothorax is suspected (eg, after an abdominal or pelvic procedure) Amylase level if esophageal perforation or pancreatitis is suspected Triglyceride levels if chylothorax is suspected (eg, after coronary artery bypass graft [CABG], especially if the inferior mesenteric artery [IMA] was used; milky appearance is not sensitive) Exudative pleural fluid can be distinguished from transudative pleural fluid by looking for the following characteristics (exudates have 1 or more of these characteristics, whereas transudates have none): Fluid/serum LDH ratio 0.6 Fluid/serum protein ratio 0.5 Fluid LDH level within the upper two thirds of the normal serum LDH level Complications of Procedure Pneumothorax (11% ) Hemothorax (0.8%) Laceration of the liver or spleen (0.8%) Diaphragmatic injury Empyema Tumor seeding Minor complications include the following: Pain (22%) Dry tap (13%)

 Cough (11%) Subcutaneous hematoma (2%) Subcutaneous seroma (0.8%) Vasovagal syncope hemopneumothorax, hemorrhage, hypotension (low blood pressure due to a vasovagal response) and reexpansion pulmonary edema. The use of ultrasound for needle guidance can minimize the complication rate.

Interpretation of pleural fluid analysis: Several diagnostic tools are available to determine the etiology of pleural fluid. Transudate versus exudate First the fluid is either transudate or exudate. A transudate is defined as pleural fluid to serum total protein ratio of less than 0.5, pleural fluid to serum LDH ratio < 0.6, and absolute pleural fluid LDH < 200 IU or < 2/3 of the normal . An exudate is any fluid that filters from the circulatory system into lesions or areas of inflammation. Its composition varies but generally includes water and the dissolved solutes of the main circulatory fluid such as blood. In the case of blood: it will contain some or all plasma proteins, white blood cells, platelets and (in the case of local vascular damage) red blood cells. Exudate:

Transudate:

hemorrhage Infection Inflammation Malignancy Iatrogenic Connective tissue disease Endocrine disorders Lymphatic disorders vs

Congestive heart failure Nephrotic syndrome Hypoalbuminemia Cirrhosis Atelectasis trapped lung Peritoneal dialysis Superior vena cava obstruction

Constrictive pericarditis

Amylase A high amylase level (twice the serum level or the absolute value is greater than 160 Somogy units) in the pleural fluid is indicative of either acute or chronic pancreatitis, pancreatic pseudocystthat has dissected or ruptured into the pleural space, cancer or esophageal rupture. Glucose This is considered low if pleural fluid value is less than 50% of normal serum value. The differential diagnosis for this is: rheumatoid effusion.The levels are characteristically low (<15 mg/dL). lupus effusion bacterial empyema malignancy tuberculosis esophageal rupture (Boerhaave syndrome) pH Normal pleural fluid pH is approximately 7.60. A pleural fluid pH below 7.30 with normal arterial blood pH has the same differential diagnosis as low pleural fluid glucose. Triglyceride and cholesterol Chylothorax (fluid from lymph vessels leaking into the pleural cavity) may be identified by determining triglyceride and cholesterol levels, which are relatively high in lymph. A triglyceride level over 110 mg/dl and the presence of chylomicrons indicate a chylous effusion. The appearance is generally milky but can be serous. The main cause for chylothorax is rupture of the thoracic duct, most frequently as a result of trauma or malignancy (such as lymphoma). Cell count and differential The number of white blood cells can give an indication of infection. The specific subtypes can also give clues as to the type on infection. The amount of red blood cells are an obvious sign of bleeding. Cultures and stains If the effusion is caused by infection, microbiological culture may yield the infectious organism responsible for the infection, sometimes before other cultures (e.g. blood cultures and sputum cultures) become positive. A Gram stain may give a rough indication of the causative organism. A Ziehl-Neelsen stain may identify tuberculosis or other mycobacterial diseases.

Cytology: Cytology is an important tool in identifying effusions due to malignancy. The most common causes for pleural fluid are lung cancer, metastasis from elsewhere and pleural mesothelioma. The latter often presents with an effusion. Normal cytology results do not reliably rule out malignancy, but make the diagnosis more unlikely.

Factors that may increase the risk of complications include:

A history of lung surgery A long-term, irreversible lung disease (such as emphysema or asthma ) Anything affecting normal blood clotting Signs of infection, including fever and chills Redness, swelling, increasing pain, excessive bleeding, or any discharge from the preseinsertion site

Pain that you cannot control with the medicines you have been given Cough, shortness of breath, or chest pain Coughing up blood Pain when taking a deep breath.

Post Thoracentesis Management Write a procedure note and describe the gross appearance of the fluid. To consider post procedure orders. The rationale for post procedure orders are as follows:

To detect complications To evaluate underlying lung To distribute specimens

Most physicians consider ordering a Hb and Hct, Chest x-ray, Vital signs and bed rest. Following the removal of 50 cc's of fluid for diagnostic purposes, very little changes occur in the patient's chest x-ray. The underlying lung can be visualized only if we deliberately evacuated the pleural space. closely monitor the patient's vital signs, CBC and chest x-ray only if one or more of the following is noted:

Blood returned in the syringe during the procedure. A difficult tap occurred requiring multiple punctures. The patient developed symptoms following the tap. There is a high risk of bleeding due to a coagulation defect. The patient is on a ventilator.

Alternate Techniques There are alternate devices available for Thoracentesis: Catheter System (Intracath and EZ Cath) These systems use a catheter that could be advanced through a needle. The usual size of the needle if 14. Once you introduce the needle into the thorax, the fluid will seep through the catheter. Advance the catheter into the pleural space. The catheter should slide is easily. A syringe is attached to the catheter and 50 cc's of fluid should be withdrawn for studies. Never pull the catheter back, with the needle still in the patient's chest, if you encounter resistance for advancement of the catheter. You will shear the catheter into the pleural space! First, slowly withdraw the catheter. Re-introduce the needle into the chest and advance the catheter only when there is a free flow of pleural fluid. Modified Husted Needle The modified Husted needle is rounded and blunt at the tip. The cutting edge is parallel to the shank axis and the needle lumen is open eccentrically on the side. The principle of Thoracentesis is the same: the blunt tip of the needle reduces the risk of puncture to the lung. The primary reason for these alternate devices is to circumvent the risk of a lung puncture by a sharp needle. This occurs during the evacuation process as the lung expands and meets the needle. This should not occur with a diagnostic Thoracentesis where only 50 ml of fluid is removed. If the effusion is small, one should certainly use one of these catheter devices for Thoracentesis. Of course, one should always use a catheter device to evacuate the fluid for a therapeutic Thoracentesis. Diagnostic yield

Almost 75% of thoracentesis yield a specific or presumptive diagnosis; 15-20% more are useful in management (e.g., rule out empyema)

Specific diagnoses: malignancy (cells), empyema (pus), tuberculosis pleurisy (AFB), fungal infection (KOH), lupus pleuritis (LE cells), chylothorax, urinothorax fluid creatinine/serum creatinine greater than 1), esophageal rupture (high fluid amylase, Ph about 6.0)

PREPROCEDURE CARE

Verify a signed informed consent for the procedure. This invasive procedure requires informed consent.

Assess knowledge and understanding of the procedure and its

purpose; provide additional information as needed. An informed client will be less apprehensive and more able to cooperate during the thoracentesis.

Preprocedure fasting or sedation is not required. Only local anesthesia is used in this procedure, and the gag and cough reflexes remain intact.

Administer a cough suppressant if indicated. Movement and coughing during the procedure may cause inadvertent damage to the lung or pleura.

Obtain a thoracentesis tray, sterile gloves, injectable lidocaine, povidoneiodine,dressing supplies, and an extra overbed table or mayo stand. These supplies are used by the physician performing the procedure.

Position the client upright,leaning forward with arms and head supported on an anchored overbed table. This position spreads the ribs, enlarging the intercostal space for needle insertion.

Inform the client that although local anesthesia prevents pain as the needle is inserted, a sensation of pressure may be felt. A pressure sensation occurs as the needle punctures the parietal pleura to enter the pleural space.

POSTPROCEDURE CARE

Monitor pulse,color,oxygen saturation,and other signs during thoracentesis. These are indicators of physiologic tolerance of the procedure.

Apply a dressing over the puncture site, and position on the unaffected side for 1 hour. This allows the pleural puncture to heal.

Label obtained specimen with name, date, source, and diagnosis; send specimen to the laboratory for analysis. Fluid obtained during thoracentesis may be examined for abnormal cells, bacteria, and other substances to determine the cause of the pleural effusion.

During the first several hours after thoracentesis, frequently assess and document vital signs; oxygen saturation; respiratory status, including, respiratory excursion, lung sounds, cough, or hemoptysis; and puncture site for bleeding or crepitus.

Frequent assessment is important to detect possible complications of thoracentesis, such as pneumothorax.

Obtain a chest X-ray. Chest X-ray is ordered to detect possible pneumothorax. Normal activities generally can be resumed after 1 hour if no evidence of pneumothorax or other complication is present.

The puncture wound of thoracentesis heals rapidly.