Thoracentesis
Indications:
- New onset pleural effusion of unclear cause.
- Pleural effusion causing symptoms of dyspnea.
- Large pleural effusions with mediastinal shift or cardiac compression.
Absolute contraindications:
- Depth of effusion < 1cm during exhalation.
- Infection over puncture site.
Consent Discussion:
Risks of procedure:
- Bleeding.
- Infection.
- Damage to the lung, diaphragm, or sub-diaphragmatic organs (e.g. liver or spleen).
- Hypotension
- Re-expansion pulmonary edema.
- Causing pneumothorax and the need for placement of a chest tube.
Equipment to obtain:
- Note: All equipment here can be found in the Davies 4 ICU.
- Personal equipment: facemask, sterile gloves.
- Procedural equipment:
- Thoracentesis kit.
- Lidocaine 1% without epinephrine.
- 10 mL syringes x2.
- Tegaderm cover.
- At least two 600mL suction vacutainer bottles
- Note: The maximum we will remove in one thoracentesis is 1.5L.
Patient preparation
1. Initial Patient Assessment
- Obtain consent for procedure.
- Have patient sitting upright, with arms crossed over a pillow on a bedside table.
- If patient unable to be seated = can use a posterolateral approach with patient supine with ipsilateral arm abducted.
- Check baseline vitals before starting (blood pressure and heart rate).
- Using the abdominal probe, place ultrasound in posterior thorax (approximately mid scapular) at area of largest effusion.
- Ideally want a location with over 2cm of fluid depth (before hitting lung).
- Fan through selected area + ensure no lung structures coming into view during respiration and assess for loculations. Scan in both longitudinal and transverse orientation.
- Ensure the diaphragm and abdominal organs are well visualized below the chosen site and do not come into view with fanning of the probe or during respiration.
- Identify insertion point + mark skin with blunt tip.
Procedural Steps:
1. Site preparation + anesthetics
- Apply chlorhexidine to area marked by ultrasound.
- Perform timeout, to ensure correct patient, correct procedure, and correct location.
- Open up thoracentesis kit + set up sterile field.
- Drop in two 10mL syringes, Tegaderm.
- Set up three-way stopcock with a 10mL syringe + drainage tubing attached.
- Put on sterile gloves, apply sterile drapes to patient in triangle format.
- Prepare lidocaine 1% without epinephrine into 5mL syringe.
- Inject lidocaine under the skin at puncture site, then add 3-5mL lidocaine deeper down the tract. Draw fluid back + inject until aspirate pleural fluid. Remove needle.
- Wait 1-2 minutes for lidocaine to take effect.
2. Catheter Insertion
- Attach insertion needle to a 10cc syringe, anchor non dominant hand onto patient thorax, then insert needle (with dominant hand) into pleural space.
- Ensure needle travels just above rib (to avoid the neurovascular bundle).
- Ensure needle trajectory is the same angle as initial ultrasound probe.
- Ensure needle trajectory roughly matches area of anesthesia.
- Ensure you are pulling back on syringe while needle is inserted.
- Once in the pleura fluid will flow into the syringe. To ensure full needle tip is fully in pleural space, push slightly further while withdrawing on syringe. Ensure that there is easy fluid flow back into the syringe.
- Thread the catheter into pleural space, then remove the needle.
- Plug the catheter with finger to prevent leaking + air entry.
- Attach prepared three-way stopcock to the catheter and ensure the valve is initially closed to the patient.
- Rotate stopcock + aspirate sample fluid using the 10cc syringe.
- Close stopcock to patient, then remove 10cc syringe, then add second 10cc syringe, rotate stopcock, again aspirate 10cc. Close stopcock to patient. Remove 10cc syringe.
- Then add final syringe to stopcock to close the open port.
- Rotate stopcock to enable drainage into the open vacutainer.
- Once the volume of desired fluid is removed (or if the patient develops chest pain, coughing, vasovagal symptoms) ask the patient to hum, then remove the catheter in one smooth movement.
- Cover insertion site with gauze + Tegaderm.
Post procedure
1. Patient Assessment
- Place patient in reclined position, monitor for 5 minutes after procedure and obtain vitals at 30 minutes post-procedure.
- Obtain post-procedure chest x-ray if any concerns including air aspirated, chest pain, dyspnea, or ongoing cough.
2. Fluid Studies
- Based on the clinical indication, consider sending fluid for: cell count and differential, protein, LDH, glucose, pH, gram stain/culture
- If concern of malignancy. send for cytology + can send full vacutainer bottle to increase sensitivity.
- Other possible tests: AFB smear, fungal stain/culture, amylase, triglycerides, cholesterol, BNP, flow cytometry.
Procedural steps written by: Muralie Vignarajah MD
Staff Reviewed by: Dr. Stephen Gauthier (Internal medicine)