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Thoracentesis

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Thoracentesis Learning Module

This web page is composed of six sections designed to re-familiarize practitioners with the Thoracentesis procedure.

Begin Module
Print all the necessary documents here or at other points throughout the module.
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*Note: This module does not replace medical training and must be used in conjunction with clinical judgment. Acting practitioner is ultimately responsible for the safety of procedures.
Print Checklist

1% lidocaine without epineprhine

SoluPrep Sterile Swabs

60cc Syringe

REF 309620

Sterile Gloves

REF 8605

Collection Bottles

Vacuum Bottle

REF S55120

Principle Risks

  • Pneumothorax 0.6 - 6.0%
  • Re-expansion pulmonary edema 0.01 - 0.5%
  • Bleeding0.18%
  • CoughVariable
  • Pain at insertion site Variable

Rare Risks

  • Infection
  • Visceral organ puncture
  • Vasovagal reaction
  • Anaesthetic/sedative reactions
  • Print Consent Form

Contraindications

  • Active infection over site
  • Extremis

Precautions

  • INR > 1.5
  • Platelet < 50,000/mm3
  • Volume < 10mm thick on decubitis Xray

There are no absolute contraindications for thoracentesis, only parameters that increase risk.

Essential Investigations

  • Cell Count & Differential
  • Culture
    +
  • Fluid Protein, LDH, glucose
  • Serum Protein, LDH, glucose
    +
  • Cytology

Targeted Investigations

  • Flow Cytometry
    +
  • AFB
    +
  • Cholesterol
    +
  • Pro-BNP Amylase RF complement
    +
Print Procedure Note

1Positioning

  • Place patient in sitting position on edge of bed with arms resting on table
  • Landmark the top of the effusion with auscultation and percussion
  • Mark needle insertion site 5-10 cm lateral to the spine and at least 1 or 2 intercostal spaces below the top of the effusion.
    • DO NOT insert needle below 9th rib

2Ultrasound

  • Visualize effusion with ultrasound and re-mark needle insertion site based on most accessible fluid pocket

3Sterilizing and Anesthetizing

  • Sterilize the area 3 times utilizing antiseptic solution
  • Dress with sterile gloves and apply a sterile drape
  • With a 25 gauge needle, inject a “wheel” of lidocaine into the dermis overlying the prospective needle insertion site
  • With a 22 gauge needle, anaesthetize the deeper tissues, intermittently aspirating, until obtaining pleural fluid. Inject a small volume of lidocaine in the pleural space

4Introducing the Catheter Device

  • Use a scalpel to create a small nick in the skin and subcutaneous tissue where you will insert your thoracentesis needle
  • Introduce your catheter device where the chest wall has been previously anaesthetized, intermittently aspirating until pleural fluid is obtained
  • Advance the plastic catheter portion (without the needle component) until the black/blue demarcating line is no longer visible

5Obtaining fluid

  • While the stopcock is in the lock position, attach a 60 cc syringe to the syringe port
  • Turn the stopcock toward the self-sealing valve and withdraw fluid into the syringe
  • When diagnostic sampling is complete, turn the stopcock to the patient port before disconnecting the syringe; divide fluid into specimen bottles (including aerobic/anaerobic culture bottles)
  • For therapeutic thoracenteses, attach a vacuum bottle(s) to drain additional pleural fluid

6Caution

  • DO NOT remove greater than 1.5 Litres
  • STOP / PAUSE the procedure if the patient develops significant cough, chest pain or increased dyspnea

7Post Procedure Care

  • Have the patient hum (or hold their breath at end expiration) while removing catheter device from the chest wall
  • Place clean bandage over procedural site
  • Order post‐procedure vitals and chest XRAY
  • Documentation sheet must be in the chart!

8

All specimens should be hand-delivered to their destinations

Videos:
Thomsen, Todd W., et al. “Thoracentesis.” New England Journal of Medicine 355.15 (2006): e16.
Kind thanks to CareFusion for their permission.

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