Thoracentesis: A Step-by-Step Procedure Guide with Photos

Authors:
V. Dimov, M.D., Clinical Assistant Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio; B. Altaqi, M.D., Assistant Clinical Professor of Medicine, University of Louisville, Kentucky

See the slide show or click on the images below for step-by-step instructions. A free PDA version of this procedure guide is available from MeisterMed, iSilo reader for PDA is required to view the images.

Indications

Pleural effusion which needs diagnostic work-up
Symptomatic treatment of a large pleural effusion

Contraindications

Uncooperative patient
Uncorrected bleeding diathesis
Chest wall cellulitis at the site of puncture

Relative contraindications

Bullous disease, e.g. emphysema
Positive end-expiratory pressure (PEEP) mechanical ventilation
Only one functioning lung
Small volume of fluid (less than 1 cm thickness on a lateral decubitus film)

Procedure Step-by-Step

Explain the procedure to the patient and obtain a written informed consent, if possible. Explain the risks, benefits and alternatives (RBA). Benefits may include less SOB, obtaining a diagnosis, and risks may include pneumothorax, bleeding, or even death.


Fig. 1. Get the standard thoracentesis kit. In addition to the kit, you will need two 1-liter vacuum bottles and Bethadine for cleaning the area. Prepare the necessary equipment for the pleural tap.


Fig. 2, 3, 4, 5. Find the anatomical landmarks before you perform the thoracentesis.


Fig. 6, 7. Clean the area with iodine.


Fig. 8, 9. Open the kit and make sure that you know which tube and needle are used for.


Fig. 10, 11. Practice sliding the flexible catheter.


Fig. 12, 13. Prepare for local anesthesia.


Fig. 14, 15. Prepare the area.


Fig. 16, 17, 18. Perform the procedure (under supervision, if you are not certified). Anesthetize the skin and pleura, try to reach the effusion fluid.


Fig. 19, 20. Prepare the flexible catheter.


Fig. 21, 22, 23, 24, 25. Pass the flexible catheter over the tap needle into the pleural space and begin aspirating the fluid in the vacuum tubes.


Fig. 26, 27.

Complete the procedure, check for complications - mainly pneumothorax and bleeding. Order a CXR to rule out pneumothorax.

Send the pleural fluid in the 1 L bottle to the laboratory. Compare the pleural fluid to the corresponding blood tests, in order to differentiate between transudate and exudate. If the patient had blood draws this morning, you can order some additional enzymes as AOT (add-on tests), if not already done before the tap.

Complications

Pneumothorax (3-30%)
Hemopneumothorax
Hemorrhage
Hypotension due to a vasovagal response
Pulmonary edema due to lung re expansion
Spleen or liver puncture
Air embolism
Introduction of infection

Write a procedure note which documents the following:

Patient consent
Indications for the procedure
Relevant labs, e.g INR/PTT, platelet count
Procedure technique, sterile prep, anesthetic, amount of fluid obtained, character of fluid, estimated blood loss
Any complications
Tests ordered

References

Thoracentesis. A Chapter in MeisterMed's Procedure Series for PDA. V. Dimov, B. Altaqi, 2/20/2007.
Thoracentesis video from the Loyola University Chicago.
Thoracentesis . The UCSF Hospitalist Handbook.
Thoracentesis video from NEJM, 2006 (paid subscription required).
Diagnostic Approach to Pleural Effusion in Adults. Am Fam Phys, Vol. 73 No. 5, April 1, 2006.
Patient information: Thoracentesis, Medline Plus.
Patient information: Pleural effusion, Medline Plus.
Is Ultrasound-Guided Thoracentesis Safer?, AFP.

Related reading

Becoming a Rural Doctor, Part 5: Procedures for the Rural Doctor. Rural Doctoring, 2008.

Thoracentesis Best Practices: Slideshow. Medscape, 2011.

Disclaimer

The material and/or content on this web site are for informational purposes only. Users of the web site should not act upon any information received from this site without seeking professional consultation. Click here for more information.

Published: 05/11/2005
Updated: 04/17/2008

Spiriva and Foradil Inhalers - How to Use them?

Tiotropium (Spiriva) is a new bronchodilator approved for COPD management. It is a long-acting, anticholinergic bronchodilator for the long-term, once-daily, maintenance treatment.
With once-daily dosing, tiotropium has greater patient compliance compared with current COPD therapy.
Price: $117
Source: AFP


This is the Spiriva inhaler called HandiHaler.


This is how you put the capsule in the Spiriva HandiHaler. Please take the time to explain to your patients not to swallow the capsules.

You can print out the instructions about the inhaler use from the Spiriva website.

Foradil (formoterol) is the long-acting beta-2 agonist that we use in our hospital, it replaced the Serevent. The problem is the same as with Spiriva - just tell your patient not to swallow the capsules but to use them in their device for inhalation.



Foradil inhaler from inside.

Foradil inhaler use is explained here. You can see it in use on the Foradil website.

Other Inhalers
The best guide for inhaler devices is published on GINA (Global Initiative for Asthma) website, they start with the really simple MDIs and go to something called Spinhaler.
You can also check all forms of inhalers and other asthma devices here. There are so many of them, no wonder it is hard to figure which is which.

Asthma Classification and Treatment
GINA website also offers a downloadable PowerPoint set on asthma classification and treatment which is another excellent resource.
There is more on the AFP website.

ICU What To Do Guide - In Detail

Author: V. Dimov, M.D.

There are 3 foundations for a successful ICU rotation:

1. Patient care comes first
2. Procedures and ACLS
3. Communication with the attending, consults and family.

Let's look at these 3 principles in detail:

Patient care

You never sleep on a patient problem that you are not sure what is going on with. You read books, check Up-To-Date, call consultants, and so on....but you must have an educated idea about the likely diagnosis and the differentials. You never think '"I'll go later" when a nurse is calling you to see a patient urgently. ICU nurses have only 1-2 patients to follow, they're very experienced and when they call you it is for a reason. That is why we have added an ICU FAQ section written by a nurse with 20 years experience - it is as useful as it gets if you are an intern.

Let's imagine an ICU scenario. The charge nurse is calling you - Mr. Jones (fiction name, don't forget HIPPA) fell off the bed, and then another page - Mr. Smith is tachying in the 150s. What to do? Dear Interns, does it sound familiar? The solution is here. In addition to asking your resident you can review the ICU FAQ. You will learn how to address common clinical situations that you will not find a quick answer for in the books.

Also always address the problem head on, never jump around it. Again if you don't know what is going on there is always somebody to ask even at 3 AM. Your attending would much prefer to be asked at 3 AM than to find the consequences of a bad management in the morning.

Procedures and ACLS

This is the big difference between the floor and the unit. Vitals signs are vital and you need to do whatever it takes to maintain them. This includes ACLS, line placement, fluids, pressors, mechanical ventilation. You need to be familiar with all these in order to provide the best patient care. There is no substitute for the experience and you should use every opportunity to get it. The old saying “see one, do one, teach one” is no longer valid. You can use our procedure guide section to see the educational videos. See 10 videos, do 10 procedures, teach 20. This should be the goal.

How to place a central line? Learn from the masters. Check out the NEJM educational video. There is a comprehensive procedure guide in the section of this website focused on procedures and ACLS.

Communication with the attending, consults and family

This is essential. Always inform your patient and the family what is going on. Often you'll be amazed to know how little your patient knows about his condition. Always discuss the code status. Advise. You're here not only to offer options but also guidance about the most appropriate decision.
Your attending and consultants are always there to help you. Inform them on time and use their immense fund of knowledge.

Imaging - EKG, CXR, CT scans

Another useful website is ICU CXR from the University of Virginia. It will answer such burning questions like "Is the central line where it is supposed to be?" or "Does he have a PTX?!"
When you have time you can review non-urgent X-rays and CT scans on the radiology website of the University of Virginia.

You can also browse through typical or not so typical EKGs here. This is a link to an arrhythmia simulator - try it out, you can pause, play and quiz yourself. Just click START on the welcome screen, you don't need a user name/password.

Published: 02/01/2004
Updated: 09/02/2005

Central Lines with Ultrasound Guidance

It is easy. Once you see how the machine works, you would never want to go back to the "blind poking". Even if you do not use the machine for the actual placement, it is encouraging to check before the procedure that the vein is there, big and ready for the needle. I still remember 2 patients - one of them did not have a patent right IJ vein. The other patient had AIDS with a viral load of 90,000, he was with PCP and on a vent. Every time he took a breath, the IJ vein collapsed. Even if you get in the vein, you cannot thread in the wire. In both cases the ultrasound helped.

We use the SiteRite ultrasound machine.

It is definitely proven that ultrasound- guided central line placement is more effective and safe than the" blind" placement.

Source: AHRQ, SCAHQ

You can check the educational brochures about the ultrasound TLC placement at the manufacturer's website.


Image source: SiteRite


References:
Procedure Skills and ACLS Refresher
Ultrasound-Guided Central Venous Cannulation. Society of Cardiovascular Anesthesiologists.
Internal Jugular Vein Cannulation - The UCSF Hospitalist Handbook
Central Venous Access. eMedicine, July 29, 2005.
VenousAccess.com Slides
Central Line Placement. Blueprints Clinical Procedures by Laurie L Marbas, Erin Case. Blackwell Publishing, access via Google Book Search.

Further reading:
Invasive procedures - BMJ 12/05

Joint Aspirations and Injections - Procedure Guides

American Family Physician is the official journal of the American Academy of Family Physicians. The journal has published a series of articles on Joint Aspirations and Injections:

- Diagnostic and Therapeutic Injection of the Wrist and Hand Region

- Diagnostic and Therapeutic Injection of the Elbow Region

- Diagnostic and Therapeutic Injection of the Shoulder Region

- Diagnostic and Therapeutic Injection of the Hip and Knee

- Diagnostic and Therapeutic Injection of the Ankle and Foot

- Knee Joint Aspiration and Injection. NEJM has a free video showing Arthrocentesis of the Knee step-by-step.

- Joint and Soft Tissue Injection

References:
Arthrocentesis of the Knee. NEJM Videos in Clinical Medicine.
Image source: pueblo.gsa.gov


Created: 04/2005
Updated: 01/13/2007

Paracentesis: A Step-by-Step Procedure Guide

Author:
V. Dimov, M.D., Clinical Assistant Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio

Indications

New onset ascites or ascites of unknown origin
Patient with a known ascites who has fever, abdominal pain, hypotension or encephalopathy
Symptomatic treatment of large ascites

Contraindications

Uncooperative patient
Uncorrected bleeding diathesis
Acute abdomen that requires surgery
Intra-abdominal adhesions
Distended bowel
Abdominal wall cellulitis at the site of puncture
Pregnancy

Procedure Step-by-Step

Explain the procedure to the patient and obtain a written informed consent, if possible. Explain the risks, benefits and alternatives (RBA).

Commercial paracentesis kits are pre-assembled. If you do not have a commercial kit, this is a list of the equipment you need to perform a successful paracentesis:

16 G Angiocath (or a spinal needle) x 1
10 cc syringe x 1
One-liter vacuum bottle x 5
Thoracentesis kit tubing x 2
Sterile gloves x 2
Betadine swab x 3
Sterile drape x 2
4x4 sterile gauze x 4
Band-aid x 1

Four steps of the paracentesis procedure

1. Ultrasound scan before the procedure
2. Patient preparation
3. Procedure
4. Laboratory results

1. Ultrasound scan before the procedure

If is is very helpful to get an ultrasound scan of the ascites before the procedure. The radiologist will mark the spot for paracentesis. Two things are important:

- What is the distance from the skin to the fluid? Usually 1 cm. It gives you an idea how deep you have to go with the needle before getting fluid in the syringe.

- What is distance to the midpoint of the collection? Usually 3 cm. It gives you an idea how deep you can go with the needle in relative safety. Generally, the advice is as soon as you reach the fluid, to advance the needle just a little and then to thread in the plastic catheter, and to take the needle out.


Ultrasound marking and direction of Angiocath needle (click to enlrage)


Ultrasound report of ascites for paracentesis

2. Patient preparation

Explain the RBA (risks, benefits, alternatives) to the patient. Make sure that he understands and agrees. If the patient does not understand the procedure, he or she cannot provide an informed consent and you have to ask a relative who has a durable power of attorney for health care or is next of kin.

Explain what is going on while performing the procedure, this will alleviate both the patient's anxiety and yours.

Ask the the patient to urinate before the procedure or use a Foley to empty the bladder. Position the patient in the bed with the head elevated at 45-60 degrees to allow fluid to accumulate in lower abdomen.

3. Procedure

Preparation for the procedure:

Get all the things ready at the bedside. Briefly explain to the patient what the different parts of kit are used for. Get a trash bin nearby to dispose of the plastic envelopes of needles and tubing.

The patient should lie on his back in a slightly recumbent position toward the site of paracentesis. Percuss the area of dullness to ensure that is correspond well the the ultrasound marking. Insertion site is inferior to umbilicus and at the level of percussed dullness, usually 2-3 fingerbreadths below the umbilicus.

Clean the area with betadine in a circular fashion from the center out. Apply the sterile drapes. You will place the opened parts of the kit on the drape.

Open the 16 G Angiocath and syringe place them on the sterile drapes. Place the 1-L vacuum bottles nearby.

From this point on, you have to wear sterile gloves, so please ensure that you have everything you need in the sterile area. It is time-consuming to have to reach for, let's say additional tubing in the non-sterile area and then to remove the soiled sterile gloves and to put new ones. Make sure that you have everything you need for the procedure in the sterile area.

Try to make sure that the Angiocath fits the tubing. All needles, syringes and tubing should fit.

Procedure technique:

If the marked site is in the RLQ, pull the skin down and go in with the Angiocath, then release the skin (this is called Z-technique which creates a skin track to stop ascitic fluid from leaking out after the procedure). Aspirate as you go in. Once you reach fluid in the needle, advance the needle just a little, then thread in the plastic part while withdrawing the needle. Aspirate again to make sure that the plastic catheter is still inside the fluid collection. If you get fluid in the syringe, everything is fine, unscrew the syringe and connect the tubing to the 1-L vacuum bottle.

If you cannot get fluid after withdrawing the needle, try to reposition the catheter. If still there is no fluid, you can try to pull out and reintroduce the needle (if kept sterile). Do not push hard or deeper than the midpoint of the collection as seen on the ultrasound scan.

If you are unsuccessful in obtaining ascitic fluid, you can ask for an ultrasound-guided paracentesis.

After the procedure, ask the patient to lie in his bed for 4 hours and the nurse to check vital signs q 1 hr for 4 hours to avoid hypotension.

It is generally recommended to give 25 cc of albumin (25% solution) for every 2 liters of ascitic fluid removed. For example, if the patient had a 4-liter paracentesis, he should receive 50 cc of albumin IV (25% solution) over 2 hours. The rationale for giving albumin is to avoid intravascular fluid shift and renal failure after a large-volume paracentesis.

Complications

Persistent leak from the puncture site
Abdominal wall hematoma
Perforation of bowel
Introduction of infection
Hypotension after a large-volume paracentesis
Dilutional hyponatremia
Hepatorenal syndrome
Major blood vessel laceration
Catheter fragment left in the abdominal wall or cavity

Write a procedure note which documents the following:

Patient consent
Indications for the procedure
Relevant labs, e.g INR/PTT, platelet count
Procedure technique, sterile prep, anesthetic, amount of fluid obtained, character of fluid, estimated blood loss
Any complications
Tests ordered

4. Laboratory results

Send the sample to the lab. Usually, you send only one of the 1-L bottles. The rest of the bottles (2-3, if it was a large-volume paracentesis) are disposed of in the biohazard area.

Order the relevant tests and check them yourself or sign out for somebody to check them.

General labs:
Ammonia, CBC, CMP, albumin, amylase, lipase, INR/PTT.

Labs for paracentesis ascitic fluid:
Protein, albumin, specific gravity, glucose, bilirubin, amylase, lipase, triglyceride, LDH
Cell count and differential
C&S, Gram stain, AFB, fungal
Cytology
pH

Your responsibility does not end with performing the procedure. You have to make sure that somebody follows on the test results and acts accordingly, e.g. prescribes antibiotics if the fluid shows SBP.


Paracentesis fluid analysis of a patient with ascites due to cirrhosis


CMP of a patient with ascites due to cirrhosis

References

Paracentesis. eMedicine.
Paracentesis. NEJM (subscription required)
Paracentesis. Blueprints Clinical Procedures, Google Books
Paracentesis. Handbook Of Gastroenterologic Procedures, Google Books
Paracentesis. Med.buffalo.edu
Practical Procedures - a complete guide
UCSF Hospitalist Handbook - Procedures
Abdominal Paracentesis. Medicineclinic.org
Medicine, Medical Books, Current Clinical Strategies Publishing
Cirrhotic Ascites - clevelandclinicmeded.com
Minimizing ascites - postgradmed.com
Patient information: Abdominal tap - Medline Plus
Arrow Large Volume Abdominal Paracentesis Kit
Videos by Proficient Procedures, Inc. USA, $ 50 for 6 procedure videos
The 'wrong' fluid. GruntDoc.com.

Related reading

Becoming a Rural Doctor, Part 5: Procedures for the Rural Doctor. Rural Doctoring, 2008.

Disclaimer

The material and/or content on this web site are for informational purposes only. Users of the web site should not act upon any information received from this site without seeking professional consultation. Click here for more information.

Published: 03/20/2006
Updated: 04/17/2008

Central Line Placement with Ultrasound Guidance: A Step-by-Step Procedure Guide with Photos (short version)

Authors: V. Dimov, M.D., Clinical Assistant Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio; B. Altaqi, M.D., Assistant Clinical Professor of Medicine, University of Louisville, Kentucky

See the slide show or click on the images below for step-by-step instructions. A free PDA version of this procedure guide is available from MeisterMed, iSilo reader for PDA is required to view the images.

In this article, we will look only at the steps that are different from the regular central line placement described on this website.


Fig. 1, 2. Ultrasound machine (SiteRite II).


Fig. 3, 4, 5. Ultrasound screen and dept adjustment switch.


Fig. 6, 7. Sterile ultrasound gel.


Fig. 8, 9, 10, 11. Put the sterile plastic cuff around the non sterile ultrasound probe.


Fig. 12, 13. Inspect the head of the ultrasound probe, position the groove to point upwards.


Fig. 14, 15, 16. Monitor the ultrasound screen during the procedure.

Do not forget to put the needles in the sharp objects collector box. Order a CXR to rule out a pneumothorax and write a procedure note.

References:
Central Line Placement (with and without ultrasound guidance). A Chapter in MeisterMed's Procedure Series for PDA. V. Dimov, B. Altaqi, 2/20/2007.
Ultrasound Guidance of Central Vein Catheterization. The evidence base of the procedure is discussed in the patient safety report of the Agency for Healthcare Research and Quality (AHRQ).
Ultrasound-Guided Central Venous Cannulation. Society of Cardiovascular Anesthesiologists.
Needlestick - GruntDoc.com
Central Venous Access. eMedicine, July 29, 2005.
VenousAccess.com Slides
Central Venous Catheterization: Concise Definitive Review. Medscape, Critical Care Medicine, 05/16/2007 (free registration required).

Created: 5/30/2005
Updated: 06/01/2007