Thoracentesis Periprocedural Care

Updated: Apr 24, 2017
  • Author: Mark E Brauner, DO; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Periprocedural Care

Patient Education and Consent

Before thoracentesis, it is important to pay attention to the consent process and provide a focused set of risks and complications, so that the patient is not surprised if he or she experiences adverse effects. [10]

Consent should be obtained from the patient or family member. The reason the procedure is being performed (suspected diagnosis); the risk, benefits, and alternatives of the procedure; the risks and benefits of the alternative procedure; and the risk and benefits of not undergoing the procedure. Allow the patient the opportunity to ask any questions and address any concerns they may have. Make sure that they have an understanding about the procedure so they can make an informed decision.

The patient should be counseled about the risks of pneumothorax, hemothorax, lung laceration, infection, empyema, damage to the intercostals, or internal mammary vessels, diaphragmatic injury, puncture of the liver or spleen, damage to other abdominal organs, abdominal hemorrhage, reexpansion pulmonary edema, air embolism, cough, pain, and catheter fragment left in the pleural space.

Discuss how these risks can be avoided or prevented (eg, proper positioning, ensuring that the patient remains as still as possible during the procedure, adequate analgesia).

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Equipment

Several commercially available medical devices are specifically designed for performing thoracentesis. Such devices include the following:

  • Arrow-Clarke Thoracentesis Device (Teleflex Medical, Research Triangle Park, NC)
  • Argyle Turkel Safety Thoracentesis System (Covidien, Mansfield, MA)
  • Critical Care Thoracentesis Set (Cook Medical, Bloomington, IN)

If a commercial use-specific device is not available, all of the necessary equipment can be obtained from the supplies located in most inpatient settings, critical care units (CCUs), or emergency departments (EDs).

  • Thoracentesis device - This typically consists of an 8-French catheter over an 18-gauge, 7.5-in. (19-cm) needle with a 3-way stopcock and, ideally, a self-sealing valve
  • Self-assembled device, if a thoracentesis device is unavailable - Options include using an 18-gauge needle or a 12-gauge intravenous (IV) catheter connected to a 60-mL syringe and then to a stopcock after the needle is removed from the 60-mL syringe
  • Injection needle – 22 gauge, 1.5 in. (3.81 cm)
  • Injection needle – 25 gauge, 1 in. (2.54 cm)
  • Luer-Lok syringe - 10 mL
  • Luer-Lok syringe - 5 mL
  • Luer-Lok syringe - 60 mL
  • Tubing set with aspiration/discharge device
  • Antiseptic - Chlorhexidine solution [Hibiclens] is preferred
  • Lidocaine - 1% or 2% solution, 10-mL ampule
  • Specimen cap for 60-mL syringe
  • Specimen vials or blood tubes
  • Drainage bag or vacuum bottle
  • Drape - 24 × 30 in., with 4-in. fenestration with adhesive strip
  • Sterile towels
  • Scalpel - No. 11 blade
  • Adhesive dressing - 7.6 × 2.5 cm
  • Gauze pad(s) - 4 × 4 in.
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Patient Preparation

Patient preparation includes adequate anesthesia and proper positioning.

Anesthesia

In addition to local anesthesia, mild sedation may also be considered. IV midazolam or lorazepam can attenuate the anxiety that may be associated with any invasive procedure. Analgesia is critically important, in that pain is the most common complication of thoracentesis. Local anesthesia is achieved with generous local infiltration of lidocaine.

The skin, subcutaneous tissue, rib periosteum, intercostal muscle, and parietal pleura should all be well infiltrated with local anesthetic. It is particularly important to anesthetize the deep part of the intercostal muscle and the parietal pleura because puncture of these tissues generates the most pain. Pleural fluid is often obtained via aspiration during anesthetic infiltration of these deeper structures; this helps confirm proper needle location.

Positioning

Patients who are alert and cooperative are most comfortable in a seated position (see the image below), leaning slightly forward and resting the head on the arms or hands or on a pillow, which is placed on an adjustable bedside table. This position facilitates access to the posterior axillary space, which is the most dependent part of the thorax. Unstable patients and those who are unable to sit up may be supine for the procedure.

One option for proper positioning of patient. Easy One option for proper positioning of patient. Easy access to the 7-9 rib space along the posterior axillary line.

The patient is moved to the extreme side of the bed, the ipsilateral hand is placed behind the head, and a towel roll is placed under the contralateral shoulder. This measure facilitates dependent drainage and provides good access to the posterior axillary space.

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