Chapter 20. Thoracentesis

• • Therapeutic drainage of pleural effusion in patient with respiratory compromise when fluid is unlikely to reaccumulate.

  • Diagnostic evaluation of pleural effusion of unknown etiology.

  • Therapeutic removal of small pneumothorax.

Relative

• • Skin infection (eg, herpes zoster) at site of insertion.

  • Bleeding diathesis, anticoagulant therapy.

  • Mechanical ventilation.

• • Sterile gloves, mask, and gown.

  • Iodinated skin preparation with sterile sponges.

  • Sterile towels.

  • Local anesthetic (1% lidocaine without epinephrine).

  • 5-mL syringe with 25-gauge needle.

  • 18-gauge 2-inch needle.

  • 18–20-gauge angiocatheter.

  • Collection basin.

  • 3-way stopcock.

  • 20–60-mL syringe.

• • Bleeding.

  • Laceration of lung or other underlying tissues.

  • Potential for need to remove additional fluid or air at a later time.

  • If fluid or air is likely to reaccumulate, then tube thoracostomy is indicated.

• • In a cooperative child, the procedure does not take more than 10–15 minutes.

  • Use lateral decubitus film to determine whether pleural effusion is free-flowing fluid or loculated.

  • Insert needle over top of rib since the neurovascular bundle is under the rib (see Figure 20–1).

• • Patient should have intravenous access.

  • Oxygen should be available.

  • Monitor oxygen saturation with pulse oximetry.

  • Younger patients may need sedation for procedure.

  • Explain procedure in a developmentally appropriate manner before and during procedure.

• • Pleural effusion.

  • • Sitting upright with arms supported on table in front of patient (see Figure 20–2).

• • • Lying in lateral decubitus position with effusion side down.

  • Pneumothorax: Supine with head of bed up 30 degrees.

• • Neurovascular bundle is on the caudad edge of the rib (Figure 20–1).

Locate Effusion

• • Chest radiograph.

  • Manual percussion to find onset of dullness.

  • • Ideal location is 1–2 cm (about 1 intercostal space) below onset of dullness.

    • Effusion is usually accessible via the sixth or seventh intercostal space just distal to the scapular tip in the midscapular line or posterior axillary line (Figure 20–2).

    • If pneumothorax is present, it is usually accessible via the second intercostal space anterior (Figure 20–3).

• • Ultrasonogram marked location.

  • • Mark location of effusion with the patient in the same position as necessary for procedure.

    • If possible, do not move patient after marking the location because the fluid may shift.

Prepare Sterile Field

• • Cleanse area in sterile fashion.

  • Drape surrounding area with sterile towels.

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