Thoracentesis

W11 Thoracentesis



J. Terrill Huggins, Steven A. Sahn, Peter Doelken



image Before Procedure



Indications



• Pleural effusion not explained by the clinical presentation

• Massive pleural effusion with impending respiratory failure

• Suspected pleural space infection

• Suspected complication of pneumonia (empyema)

• Suspected hemothorax


Contraindications



• Absolute:
• Lack of expertise

• Severe uncorrectable coagulopathy (platelet count <25,000 cells/µL; international normalized ratio [INR] >2.0)

• Azotemia (creatinine >6 mg/dL)

• Uncooperative patient

• Relative:
• Operator dependent and of technical nature

• Lack of image guidance to determine safety of puncture site


Equipment



• Diagnostic thoracentesis:
• Iodophor- and chlorhexidine-containing antiseptic

• 10- and 30-mL sterile syringes

• 21-gauge needle

• 21-gauge spinal needle may be needed for obese patients

• 1% lidocaine for local anesthetic

• Therapeutic thoracentesis:
• Commercially available catheter-over-needle system


image Anatomy


The pleura is a serous membrane that covers the lung parenchyma, mediastinum, diaphragm, and rib cage. The pleura is divided into the visceral and parietal pleura. The visceral pleura covers the lung parenchyma as well as the interlobar fissures. The parietal pleura lines the inside of the chest wall and the diaphragm. As pleural fluid forms, separation of the visceral and parietal pleural occurs, creating a space for a needle to be placed safely. Free-flowing pleural fluid will collect through gravitational effects in dependent areas, so if a patient is sitting upright, pleural fluid will collect along the diaphragm and the costophrenic and cardiophrenic angles. In contrast, in a supine patient, pleural fluid will collect along the posterior aspects of the lung.


The parietal pleural receives its blood supply from the systemic capillaries of intercostal arteries supplying the costal pleura, whereas the mediastinal pleura is supplied by the pericardiophrenic artery. The diaphragmatic pleura is supplied by the superior phrenic and musculophrenic arteries. The bronchial arteries probably supply the visceral pleura. The intercostal artery, vein, and nerve travel below the ribs. It is important to understand that the neurovascular bundle is not protected by the phalange of the rib within the first 8 to 10 cm from the origin of the vessels and nerves from the spine. Performing a thoracentesis in close proximity to the spine increases the risk for intercostal artery laceration and hemothorax.

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Jul 7, 2016 | Posted by in CRITICAL CARE | Comments Off on Thoracentesis

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