17 Thoracentesis

Indications

By Presentation

By Etiology/Fluid Type

Contraindications

Relative Contraindication

Preprocedural Evaluation

Evaluate Prior Cross-Sectional Imaging

• Evaluate
  
  
  
  • The size and extent of pleural effusion
    
  • If there is focal wall thickening or associated masses to help identify or confirm the suspected diagnosis
    
  • If enhancing pleura (collection wall) is due to infection, tumor, or subacute/chronic hemothorax
    
  • For hints of loculation of pleural fluid
    
    
    
    • Shifting of fluid from one computed tomography (CT) scan to the next, or from plain film radiographs (Fig. 17.1)
      
      
      

      
      

      

      
      

      Fig. 17.1 Drainage of postoperative infected pleural space (empyema). (A) Unenhanced axial computed tomography (CT) image of the lower chest in a patient status postthoracic surgery demonstrated thick-walled loculated collections (arrows) in the pleural space. One of these locules has a thick wall (asterisk in center of it). A large-bore surgically placed chest tube is seen in the chest bases, posteriorly (arrowhead). (B) Gray-scale ultrasound image of the fluid collection in Fig. 17.1A (top) and schematic sketch of it (bottom). A 21-gauge needle has been advanced into the pleural collection (arrow). The underlying lung is seen (asterisk) (LE, loculated pleural effusion). (C) Gray-scale ultrasound image of the fluid collection in (top) and schematic sketch of it (bottom). A 10-French drain (arrow) is now seen in the target pleural collection (LE, locu-lated pleural effusion). The underlying lung is seen (asterisk).

      
      
    • Lobulation of the pleural fluid in pockets within the thoracic cavity (Fig. 17.1)
      
    • High-density fluid (>30 HU) that may represent infected fluid, bile, or blood – has a high probability of septations and/or loculations
  
  
• Prior ultrasound images/evaluations of the pleural space may show septations within the pleural fluid (Fig. 17.2).
  
  
  

  
  

  

  
  

  Fig. 17.2 Gray-scale ultrasound image of a septated pleural effusion (top) and schematic sketch of it (bottom). Numerous septa are seen (arrowheads) crisscrossing the pleural effusion (E).

  
  
  
  
  • The septations may indicate that a simple tube/drain placement may not adequately drain all the fluid in the pleural space.
    
  • This is an indication that the septations may require wire break-up during the procedure (see Fluoroscopic-guided wire and tube access).
  
  
• Look for adjacent organs that can be inadvertently traversed
  
  
  
  • Transgression of organs is not a common problem.
    
  • It may be more common with small amounts of sub-pulmonic fluid, which raise the technical difficulty of a thoracentesis.
    
  • Organs that may be transgressed include the lung, spleen (left thoracentesis), and liver (right thoracentesis).
    
  • Plan a thoracentesis that is safe and away from adjacent structures such as the descending thoracic aorta particularly in left-sided posterior thoracentesis in the elderly with ectatic aorta

Evaluate Preprocedure Laboratory Values

• Laboratory value evaluation mostly revolves around ruling out coagulopathy.
  
  
  
  • Suggested coagulopathy thresholds for thoracentesis are
    
    
    
    • International normalized ratio (INR): ≤1.7
      
    • Platelets (PLT): ≥50,000–70,000
      
    • Activated partial thromboplastin time (aPTT): ≤5 seconds

Obtain Informed Consent

• Indications
  
  
  
  • See Indications above
    
  • Technical success in placing a drain in the gallbladder is high (98–100%).
    
  • Technical success of ultrasound-guided thoracentesis after failed “blind” or clinical/palpation thoracentesis is 88%.
  
  
• Alternatives
  
  
  
  • To refuse the procedure
    
  • Bedside, nonimage-guided thoracentesis
    
  • Surgically placed large-bore chest tube
    
  • Video-assisted thoracotomy drainage (VAT)
    
  • Surgical decortication in loculated and chronically infected pleural space
  
  
• Procedural risks
  
  
  
  • Major complications occur in 1–5% of patients.
    
  • Common postprocedural morbidity symptoms (part of the spectrum of complications) are listed in Table 17.1.
    
    
    

    
    

    

    
    
  • Infection (Table 17.2)
    
    
    

    
    

    

    
    
    
    
    • This complication is not mentioned (rare) in thoracenteses studies; however, it is theoretically possible, although difficult to prove, that infection can be introduced into a sterile pleural effusion.
    
    
  • Bleeding (Table 17.2)
    
    
    
    • Bleeding occurs in <2–3% of patients.
      
    • Bleeding can occur as site (peritube) bleeding/hematoma (0.5%), hemothorax (<2.0%), or hemoptysis (0.1%).
      
    • It may present as pain and/or hypotension and a CT scan may show
      
      
      
      • Enlarging hydrothorax now with high density (>45 HU) fluid (blood)
        
      • Active extravasation in the few cases where CT intravenous (IV) contrast is used
      
      
    • Bleeding may be transient with or without blood transfusion.
      
    • The source of bleeding is usually an intercostal artery; it is usually self-limiting.
      
    • In rare cases, bleeding may require intervention such as transcatheter intercostal arterial embolization or exploratory surgery (thoracotomy).
    
    
  • Injury to surrounding organs and/or structures (Table 17.2)
    
    
    
    • Lung
      
    • Spleen, liver
    
    
  • Pneumothorax (Table 17.2)
    
    
    
    • Occurs in <5% of cases
      
    • Incidence varies depending on whether a routine chest x-ray (CXR) is performed after the thoracentesis or not. This is controversial. Some institutions perform a CXR only in symptomatic patients; other institutions perform at least one CXR after all thoracenteses.
      
    • 33% of patients with pneumothoraces are symptomatic.
      
    • 25% of patients with pneumothoraces have chest pain.
      
    • 25% of patients with pneumothoraces have shortness of breath.
      
    • 57% of patients with shortness of breath have pneumothoraces.
      
    • 16% of patients with chest pain have pneumothoraces.
      
    • 10–40% of patients with pneumothoraces require a chest tube to be placed.

Equipment

Ultrasound Guidance

Standard Surgical Preparation and Draping

Local Infiltrative Analgesia Administration

Sharp Access Devices

Tubular Access Devices

Suction/Water Seal Devices

Technique

Related posts:

Superficial Lymph Node Biopsy Management of Postcatheterization Pseudoaneurysm Endovaginal Procedures Liver Biopsy Percutaneous Nephrostomy Percutaneous Cholecystostomy

Stay updated, free articles. Join our Telegram channel

Join