Thoracentesis

Consent: Prior to performing the procedure, consent must be obtained from either the patient or a surrogate decision maker, and the proper consent form must be signed. Review the procedure, potential benefits, potential risks, and complications.

Position: Raise the patient’s bed to an appropriate height to avoid hunching over during the procedure. Put the bed rail down at the side from which you will be performing the procedure. The patient should be sitting up at the edge of the bedside. Place a table in front of the patient with a pillow on top and have the patient lean over with their arms forward placed on the table to pull the scapula away from the procedure site. If the patient is unable to sit upright, the lateral recumbent or supine position may be used.

Ultrasound Survey: Utilizing the phased array probe, you will use the ultrasound to find an appropriate site for thoracentesis using the landarks detailed below. The probe marker should be facing the patient’s head. Look for a site where the pleural fluid is ideally at least 3 cm deep that is devoid of lung or surrounding organs. Once you find a potential site, fan and rock the ultrasound to ensure lung does not enter the site. If unable to find a deep enough accessible window without surrounding organs, the procedure must be aborted.

1. Triangle of safety: The safest site for thoracentesis is anterior to the mid axillary line, above the level of the nipple, and below/lateral to to the pectoralis major

2. Posterior: Assess the posterior midscapular line and ensure you are above the 9th rib to avoid intra- abdominal injury

Palpate: Palpate the site to find the superior border of the rib as this is where you will puncture to avoid the intercostal vessels that run along the inferior border of the rib

Mark: Mark the site at the superior rib border using a 5 cc syringe by using pressure against the blunt end of the syringe to the skin. Draw back on the syringe, hold for a few seconds, and then remove. Once the site is marked, confirm the position with your ultrasound. Once confirmed, you will no longer need the ultrasound during the procedure.

Sterilize: Put on sterile gloves (see sterile approach tab for more detailed information). Open the chloraprep antiseptic swabstick included in the paracentesis kit. Sterilize the insertion site you located previously, starting at the insertion site and moving outwards in a circular manner for at least 2 min. Allow it to completely dry before starting the procedure.

Drape: The drape is included within the paracentesis kit. Remove the sticker lining. Align the opening of the drape at the cannulation site and stick the drape onto the site.

Time Out: Physician and RN will perform time out together in front of the patient. You will confirm the 3 P’s - proper patient, procedure, and location. Review allergies and confirm that informed consent was obtained.

Anesthetize: Open the lidocaine, swab the top of the vial with an alcohol pad, and attach the blunt needle to the syringe. The blunt needle allows you to draw the lidocaine into the syringe as it has a bigger diameter, however, you cannot inject the patient using this needle. Once lidocaine is drawn into the syringe, change the blunt needle tip to 22 or 25 gauge anesthetizing needle. Create a wheal at the site of insertion, however, aspirate prior to pushing lidocaine to ensure you are not in a vessel. Once a wheal is created, you will anesthetize deeper along the tract of the catheter. Insert your needle vertically into the insertion site aiming for above the superior border of the rib, aspirate to ensure no blood return, push medication, advance needle and repeat (Advance, Aspirate, Push Medication). Do this until you feel a sudden loss of resistance indicating the needle has entered the pleural space, and inject additional anesthetic as the parietal pleura is highly sensitive. Withdraw the needle.

Puncture: Using a scalpel, puncture the marked site by inserting the blade straight down a few cm to create a nick to allow for passage of the catheter. Tip: Inserting the blade is a more effective technique rather than using a flicking motion.

Positioning needle: The catheter component includes the needle within the catheter, stop cock, and 10 cc syringe for aspiration. Using your dominant, hold the plunger of the syringe to allow you to aspirate throughout the procedure. Rest the dorsal surface of your nondominant hand against the patient’s abdominal wall for stability while holding the distal end of the catheter with your thumb and first finger. This will allow you to feed the catheter through the puncture site you created while stabilizing yourself against the patient and preventing the catheter from bending.

Insertion: Insert the needle into the puncture site aiming towards the superior border of the rib. Pull back on the syringe plunger as you advance the needle until you feel a loss of resistance entering the pleural space and aspirate pleural fluid within the syringe. Once you see this, advance the needle 1-2 mm further and reconfirm good flow of pleural aspirate within the syringe.

Advance catheter: While holding the syringe, brace your dominant arm against you so that the needle doesn’t move. Use your non-dominant hand to advance the catheter until it is flush with the skin, and then remove the needle (See how to advance the catheter in equipment checklist section)

Collection:

1. Direction of stop cock: The 3 way stop cock can be open towards the patient, away from the patient towards the initial 10 cc syringe that was used to aspirate during insertion of the needle, and towards the third component of the stop cock to which you will attach a 60 cc syringe for diagnostic or the high pressure tubing system for therapeutic. The direction towards which the stop cock is facing means that the valve is closed in that direction and open towards the other directions. When you are attaching the tubing or the syringe for sampling keep the stop cock off towards the patient to prevent any air from entering the pleural space. Once things are connected, turn the stop cock away from the patient to allow pleural fluid flow from the patient and into the syringe or tubing.

2. Diagnostic: Turn the stop cock towards the patient to prevent air from entering the pleural space. Attach the 60 cc syringe to the third component of the 3 way stop cock. Turn the stop cock so that it is facing away from the patient. This will ensure that the component is open towards the patient and towards the 60 cc syringe. Withdraw pleural fluid. Turn the stop cock towards the patient, remove the 60 cc syringe from the stop cock, and pour it into the available vials within the kit, a grey top container in case the lab needs additional fluid for studies, and cytology vial if indicated.

3. Therapeutic: There are two types of tubing systems depending on what kit you obtain, one with a one way valve and one without one that will require an extra 3 way stop cock. You can either attach the distal end of the tubing to the collection bag. Or you can attach the spiked tip component to the distal end of the tubing, and then insert the spiked end into an evacuation container. Tip: You should NOT remove more than 1.5L to prevent post expansion pulmonary edema. It is normal for the patient to cough during the procedure due to expansion of the lung, however, if the coughing becomes significant and bothersome, slow down fluid removal or abort the procedure.

   1. Tubing with one way valve- Turn the stop cock towards the patient to prevent air from entering the pleural space. Attach the tubing to the 3rd component of the 3 way stop cock and connect the 60 cc syringe to the extra port on the tubing system. Turn the stop cock away from the patient, aspirate fluid into the 60 cc syringe, and then push the fluid out of the syringe which will enter the one way valve and into the collection bag.

   2. Tubing without one way valve - Turn the stop cock (Stop cock #1) towards the patient to prevent air from entering the pleural space. Attach an additional 3 way stop cock (Stop cock #2) to the 3rd component of stop cock #1. Attach the 60 cc syringe and the tubing system to the other 2 ports of stop cock #2 and turn the stop cock towards the collection bag so that it is open towards stop cock #1 and towards the 60 cc syringe. On stop cock #1, turn the stop cock away from the patient so that its open towards the patient and towards stock cock #2. Aspirate fluid into the 60 cc syringe, turn the stop cock on stop cock #2 towards stop cock #1, and push the fluid in the syringe into the collection bag. Then repeat.

Remove catheter: Remove the catheter as the patient either hums or holds their breath at the end of expiration.

Dressing: Apply pressure against the site with gauze, and then apply a bandaid.