To find the level, use UTS or put stethoscope on the back and tap the sternum with your fingers…
What to Send
Red tube (LDH, protein, glucose, amylase, triglycerides, and perhaps albumin)
Lavender (cell count)
ABG syringe for pH
Two extra tubes
Extra red to hold
Bag for cytology (or green top)
Also red top full of blood for LDH, Amylase, Trig, Protein
Some believe: avoid taking off more than 1 ½ liters to avoid reexpansion pulmonary edema
a catheter length of 5 cm would only reliably penetrate the pleural space of 75% of patients. A longer catheter should be considered, especially in women (AEM Feb 2004)
Consider using ultrasound to guide your puncture site. In those cases where a puncture site was proposed clinically, 1/4 of them were deemed dangerous and inaccurate. Ultrasound was able to demonstrate a safe site in half of the cases when clinical exam did not yield a site. (Chest 2003, 123:436-441)
can use one lumen central line.
sit pt up to 45
attached to urine drainage bag adapted to iv set with drip chamber cut off
is it a safer method? Jones PW, Moyers JP, Rogers JT, Rodriguez RM, Lee YC, Light RW. Saint Thomas Hospital, and Vanderbilt University, Nashville, TN 37205, USA. STUDY OBJECTIVES: The objectives of this study are as follows: (1) to determine the incidence of complications from thoracentesis performed under ultrasound guidance by interventional radiologists in a tertiary referral teaching hospital; (2) to evaluate the incidence of vasovagal events without the use of atropine prior to thoracentesis; and (3) to evaluate patient or radiographic factors that may contribute to, or be predictive of, the development of re-expansion pulmonary edema after ultrasound-guided thoracentesis. DESIGN: Prospective descriptive study. SETTING: Saint Thomas Hospital, a tertiary referral teaching hospital in Nashville, TN. PATIENTS: All patients referred to interventional radiology for diagnostic and/or therapeutic ultrasound-guided thoracentesis between August 1997 and September 2000. RESULTS: A total of 941 thoracenteses in 605 patients were performed during the study period. The following complications were recorded: pain (n = 25; 2.7%), pneumothorax (n = 24; 2.5%), shortness of breath (n = 9; 1.0%), cough (n = 8; 0.8%), vasovagal reaction (n = 6; 0.6%), bleeding (n = 2; 0.2%), hematoma (n = 2; 0.2%), and re-expansion pulmonary edema (n = 2; 0.2%). Eight patients with pneumothorax received tube thoracostomies (0.8%). When > 1,100 mL of fluid were removed, the incidence of pneumothorax requiring tube thoracostomy and pain was increased (p < 0.05). Fifty-seven percent of patients with shortness of breath during the procedure were noted to have pneumothorax on postprocedure radiographs, while 16% of patients with pain were noted to have pneumothorax on postprocedure radiographs. Vasovagal reactions occurred in 0.6% despite no administration of prophylactic atropine. Re-expansion pulmonary edema complicated 2 of 373 thoracenteses (0.5%) in which > 1,000 mL of pleural fluid were removed. CONCLUSIONS: The complication rate with thoracentesis performed by interventional radiologists under ultrasound guidance is lower than that reported for non-image-guided thoracentesis. Premedication with atropine is unnecessary given the low incidence of vasovagal reactions. Re-expansion pulmonary edema is uncommon even when > 1,000 mL of pleural fluid are removed, as long as the procedure is stopped when symptoms develop.Joe Lex, MD, FAAEM Department of Emergency Medicine 1009 Jones Hall – Broad & Ontario Temple University School of Medicine Philadelphia, PA 19140 215 707.5036 Office 215 707.3494 Fax
Most uts-guided pneumothoraces are the result of non-expandable lungs, they are usually not preventable (Chest 2006;130;1173-1184)
Safety Summary from PulmCCM
from the study (Thorax 2015;70:127-132)
- No blood products for coagulopathy or platelets for thrombocytopenia were provided to reduce thoracentesis bleeding risk.
- No routine chest films after thoracentesis.
- Bilateral thoracenteses were performed sequentially (without delay) about 40% of the time.
- Patients on ventilators were not routinely excluded.
- Ultrasound and hand suction (not vacuum bottles) were used routinely; pleural manometry was not.
Authors tracked patient factors (e.g., on a ventilator), procedure factors (needle passes, volume removed), and complication rates, which were 0.98% overall, including:
- Iatrogenic pneumothoraces (0.6%)
- Re-expansion pulmonary edema or REPE (0.01%), with no deaths
- Bleeding episodes (0.18%), of which 5 were considered hemothorax (0.05%)
- Vasovagal reactions (0.06%)
Removing >1,500 mL was associated with more complications (3.1% overall), including 2.2% pneumothorax risk and 0.75% risk for re-expansion pulmonary edema.
Severe thrombocytopenia did not increase bleeding risk: among 53 patients with platelets under 20,000, there were no cases of hemorrhage. There was no association between INR and bleeding risk, among 301 patients undergoing thoracentesis with INR >3.1. Interestingly, elevated PTT was associated with complications (authors suspect as a marker for underlying disease or frailty).
Invasive or non-invasive mechanical ventilation did not increase the likelihood of a complication, among 1,377 patients. Unfortunately, the analysis was not stratified between invasive and non-invasive ventilation.
Two or more needle passes were associated with increased risk for pneumothorax. In an indication of their high proficiency, authors completed thoracentesis with one needle pass >99% of the time. They reported “dry taps” (zero fluid) in only 35 patients (0.4%). Authors believe they probably over-counted, rather than under-counted pneumothoraces (i.e. counting some cases of trapped lung as pneumothorax).