Thoracentesis

Question 1

What are the subjective factors to consider before thoracentesis?

Answer 1

• History of malignancy, pancytopenia, anticoagulant use, pleural effusion
• Signs and symptoms: Small pleural effusions are usually asymptomatic. Large pleural effusions may cause dyspnea, pleuritic chest pain, and dry cough.

Question 2

What are the objective factors to consider before thoracentesis?

Answer 2

• Patient evaluation: General appearance, vital signs, fever, pulse oximetry.
• Physical exam: Findings consistent with the presence of a larger pleural effusion include dullness to percussion.

Question 3

What diagnostic tests are recommended before thoracentesis?

Answer 3

• Chest x-ray (PA and lateral)
• Fluoroscopy or CT scan may be useful before thoracentesis
• Current CBC with platelets and differential, PT/PTT.

Question 4

What are the risks and benefits of thoracentesis?

Answer 4

• Risks: Pneumothorax, hemothorax, infection (Empyema), unilateral pulmonary edema, laceration of intra-abdominal viscera, subcutaneous emphysema, air embolism, pulmonary laceration.
• Benefits: Yield information which may be lifesaving or significantly alter treatment, relief of respiratory distress.

Question 5

What steps should be taken to prepare the patient for thoracentesis?

Answer 5

• Obtain consent from the patient or appropriate legal designee.
• Check platelet count and/or presence of coagulopathy.
• Explain the procedure, risks/benefits, and steps to the patient.
• Check patient history for hypersensitivity to local anesthetic and Chlorhexidine.

Question 6

What is the recommended patient position for thoracentesis?

Answer 6

• The preferred position is sitting with arms and head supported on a bedside adjustable table. If unable to sit, the patient should lie on the affected side with the arm over the head.

Question 7

What is the usual site for needle insertion in thoracentesis?

Answer 7

The usual site for insertion is the posterolateral aspect of the back over the diaphragm, but under the fluid level. The site is confirmed by counting the ribs based on the chest x-ray and percussing out the fluid level.

Question 8

What should be done during needle insertion in thoracentesis?

Answer 8

• Anesthetize the skin and superior surface of the rib and pleura.
• Insert the needle over the top of the rib to avoid intercostal nerves and blood vessels.
• Aspirate back on the syringe to check for pleural fluid and note the depth of the needle.

Question 9

How is the pleural fluid drained in thoracentesis?

Answer 9

• Attach the three-way stopcock and tubing and aspirate the desired amount of fluid.
• Evacuate the fluid through the tubing.
• Generally, not remove more than 1500 ml of fluid at any one time to avoid complications.

Question 10

What should be done after thoracentesis?

Answer 10

• Obtain an upright portable chest x-ray to evaluate the fluid level and rule out pneumothorax.
• Send the pleural fluid for appropriate lab tests.
• Provide post-procedural analgesics as needed.