Thoracentesis

Indications

  • New-onset pleural effusion (except obvious CHF-induced effusion)
  • Symptomatic pleural effusion

Contraindications

Thoracentesis if coagulopathic

  • Platelets <50K[1]
  • INR >2x normal[1]
  • Mechanical ventilation

Equipment Needed

  • Thoracentesis kit
  • Sterile gloves
  • Chlorhexidine or betadine scrub
  • Evacuated container
  • Ultrasound

Procedure

  • Choose insertion site/positioning
    • Upright position in mid-scapular or posterior axillary line (usual technique)
    • Lateral decubitus position with fluid side down in post axillary line (if cannot sit up)
    • Supine with head elevated as much as possible in midaxillary line (chest tube location)
  • Cleanse skin with chlorhexidine or betadine
  • Anesthetize skin and subcutaneous tissue - raise wheal and advance/inject along superior aspect of lower rib (avoid NV bundle)
  • Make small skin nick with scalpel
  • Insert/advance needle while continuously aspirating until pleural space is entered
  • Advance catheter into pleural space while removing needle
  • Connect tubing to catheter and to evacuated container and remove desired amount of fluid
  • Obtain post-procedure CXRif:
    • Multiple needle passes required
    • Air is aspirated
    • Risk of adhesions
    • New-onset of symptoms during the procedure (chest pain, dyspnea)
    • Patient at high risk for decompensation from small pneumothorax (lung disease, positive pressure ventilation)

Complications

  • Pneumothorax (4-19%)
  • Cough (9%)
  • Infection (2%)
  • Hemothorax
  • Splenic injury
  • Diaphragmatic injury
  • Hepatic Injury
  • Vascular injury/bleeding
  • Reexpansion pulmonary edema
    • Treatment should include supportive care with noninvasive ventilation as needed
    • Diuresis is not a primary treatment for reexpansion pulmonary edema

See Also

Pleural Effusion

References

  1. 1.0 1.1 McVay P. et al. Lack of increased bleeding after paracentesis and thoracentesis in patients with mild coagulation abnormalities. Transfusion. 1991 Feb;31(2):164-71