PLEURAL FLUID TAPPING
MODERATOR:DR BALACHANDRA A .SHETTY
PRESENTOR:DR K HARIKIRAN
INDICATIONS
1) Evaluation of Etiology of new pleural effusion
2) Relieve from Dyspnea associated with Large Pleural effusion
Contraindications
ABSOLUTE :
-None
RELATIVE:
1)Platelets <50
2)INR >2 times upper limit of normal
3) Cellulitis
4)Mechanical or Manual ventilation
EQUIPMENTS
● Local anesthetic (eg, 10 mL of 1% lidocaine), 25-gauge and 20- to 22-gauge
needles, and 10-mL syringe
● Antiseptic solution with applicators, drapes, and gloves
● Thoracentesis needle and plastic catheter
● 3-way stopcock
● 30- to 50-mL syringe
● Wound dressing materials
● Bedside table for patient to lean on
● Appropriate containers for collection of fluid for laboratory tests
● Collection bags for removal of larger volumes during therapeutic
thoracentesis
● Ultrasound machine
PROCEDURE:
1)Place the patient in sitting position on edge of bed with arms resting on table.
Lateral recumbent position if patient is unable to sit upright position(posterior
axillary line)
PERCUSSION
2)The effusion should be localised using auscultation ,percussion and tactile
Fremitus on posterior chest wall or by Ultrasonography.
3)The thoracocentesis site should be in the mid scapular or posterior axilliary line
(6-10cm from lateral to spine) and 1 to 2 intercostal spaces below the highest level
of effusion.
4) To minimize potential injury of the diaphragm, the lowest recommended level for
thoracentesis is between the eighth and ninth ribs (eighth intercostals space).
5)Mark the area of needle insertion by marking with pen on skin .
6) Prepare area with antiseptic solution and apply sterile Drape .
7)Using 25 gauge ,place wheel of lidocaine along the superior edge of rib that below
selected intercostal space and switch to 22 gauge needle to anaesthetize deeper
tissues.
8)Inferior surface of rib must be avoided since intercostal vessels and nerves are
located at this region
9)Push needle over superior aspect of rib ,alternatively injecting anaesthetic and
pulling back on plunger as we advance ,once needle enter pleural space ,pleural
fluid will begin to fill syringe.
Inject more anaesthetic at this point ,to anaesthetise the highly sensitive
parietal pleural.
10)Note depth of penetration and withdraw needle ,if available a haemostat may
be attached to exposed portion of needle to mark depth of pleural space .
PLEURAL FLUID ASPIRATION
1)Using the scalpel, nick the skin at the area of needle insertion, creating a 2-3 mm incision.
2) insert and advance the 8 Fr catheter over needle assembly, perpendicular to the skin and toward the
upper edge of the rib, then walk the needle superiorly to the intercostal space.
3) Once pleural fluid is returned in the syringe, advance the needle further 3-4 mm to ensure the
catheter tip is inside the pleura.
4)Keeping the needle assembly stable, advance the catheter over the needle into the pleural space.
5)Withdraw the needle, leaving the catheter in place. As the needle is removed from the catheter hub,
the hub will lock automatically. Once the needle is removed, the hub cannot be unlocked and the
needle cannot be reinserted. This is designed to prevent accidental air entry into the pleural space.
6)Attach the Y-tubing to the three way stopcock assembly on the catheter hub.
The short arm of the Y goes to the 60 mL syringe, the long arm to the collection
bag, and the neck to the catheter hub.
7)Open the stopcock by moving the valve to the open position and, using the 60
mL syringe, aspirate 60 mL of fluid. Remove the syringe and set aside to
inoculate the culture tubes.
8)Attach the spare 60 mL syringe and aspirate to fill the collection bag. The tubing
assembly contains a one way valve system that allows the operator to aspirate
fluid into the syringe and then empty the syringe directly into the collection bag
without reconfiguring the tubing.
9)Remove fluid by alternating pulling and pushing the syringe plunger until no
additional fluid can be removed or a total of no more than 1,500 mL of fluid has
been removed.
Limiting fluid removal to 1,500 mL is advised in order to reduce the risk of re
expansion pulmonary edema.
10)When fluid removal is complete, close the stopcock to the patient, and instruct
the patient to hum in order to generate positive intrathoracic pressure.
While the patient hums, remove the catheter in a single, smooth movement
and cover the entry site with a sterile bandage.
POST PROCEDURAL CONSIDERATIONS:
1.A CHEST X RAY SHOULD DO TO RULE OUT PNEUMOTHORAX AND TO
COMPARE LUNGS BEFORE AND AFTER PROCEDURE
2.DOCUMENT PROCEDURE,PATIENT RESPONSE,CHARACTERISTICS OF
FLUID AND AMOUNT
3.POST PROCEDURAL ANALGESICS FOR OAIN AT INCISION SITE.
4.VITALS MONITORING
COMPLICATIONS
1)PNEEUMOTHORAX
2)REEXPANSION PULMONARY EDEMA
3)RESPIRATORY DISTRESS
4)AIR EMBOLISM
5)HEMOTHORAX
6)INFECTION
THANK YOU
