PROCEDURE Thoracentesis (Assist) 28 Susan Yeager PURPOSE: Thoracentesis is performed to assist in the diagnosis and therapeutic management of patients with pleural effusions.

PREREQUISITE NURSING hypotension, cough, pain, visceral injury, and reexpansion 4–6 KNOWLEDGE pulmonary edema. • The most common complications from pleural aspiration • Thoracentesis is performed with insertion of a needle or are pneumothorax, pain, hemorrhage, and procedure a catheter into the pleural space, which allows for removal failure. The most serious complication is visceral injury. 5 of pleural fl uid. • Hypotension can occur as part of the vasovagal reaction, • Pleural effusions are defi ned as the accumulation of fl uid causing bradycardia, during or hours after the procedure. in the pleural space that exceeds 10 mL and results from If it occurs during the procedure, cessation of the proce- the overproduction of fl uid or disruption in fl uid dure and intravenous (IV) atropine may be necessary. If reabsorption.1 hypotension occurs after the procedure, it is likely the • Diagnostic thoracentesis is indicated for differential diag- result of fl uid shifting from pleural effusion reaccumula- nosis for patients with pleural effusion of unknown etiol- tion. In this situation, the patient is likely to respond to ogy. A diagnostic thoracentesis may be repeated if initial fl uid resuscitation.7 results fail to yield a diagnosis. • Development of cough generally initiates toward the • Therapeutic thoracentesis is indicated to relieve the symp- end of the procedure and should result in procedure toms (e.g., dyspnea, cough, hypoxemia, or chest pain) cessation. caused by a pleural effusion. • Reexpansion pulmonary edema is thought to occur from • Samples of pleural fl uid are analyzed and assist in distin- overdraining of fl uid too quickly. The incidence is less guishing between exudative and transudative etiologies of than 1%, but asymptomatic radiological pulmonary edema effusion. Results of laboratory tests on pleural fl uid alone may be slightly more frequent. 5 The maximum volume of do not establish a diagnosis; instead the laboratory results fl uid that can be safely removed is uncertain because the must be correlated with the clinical fi ndings and serum volume removed does not clearly correlate with the onset laboratory results. of symptoms. Traditionally, to avoid this complication, • Exudative effusions indicate a local etiology (e.g., pulmo- discontinuation of fl uid removal occurs with the onset of nary embolus, infection), whereas transudative effusions symptoms or when the total fl uid removed reaches 1000 usually are associated with systemic etiologies (e.g., heart to 1500 mL.5,6 failure). • If using continuous positive airway pressure, caution • Relative contraindications for thoracentesis include the should be taken to avoid potential pneumothorax follow- following: ing aspiration if there is no pleural drain in place. 5 Patients ❖ Patient anatomy that hinders the practitioner from receiving positive airway pressure can undergo thoracen- clearly identifying the appropriate landmarks tesis with an ultrasound-guided incidence of less than 7% 4,8 ❖ Patients actively undergoing anticoagulation therapy or pneumothorax noted. with an uncorrectable coagulation disorder ❖ Patients receiving positive end-expiratory pressure EQUIPMENT therapy ❖ Patients with splenomegaly, elevated left hemidia- • Indelible marker phragm, or left-sided pleural effusion • Sterile gloves ❖ Patients with only one lung as a result of a previous • Sterile drapes pneumonectomy • Sterile towels ❖ Patients with known lung disease • Adhesive bandage or adhesive strip ❖ Patients with active skin infection at the point of needle • Antiseptic solution insertion4 • Sterile 4 × 4 gauze pads • Ultrasound scan–guided thoracentesis is thought to reduce • Intervention medications (opioid, sedative, or hypnotic complications. agents, local anesthetic 1% or 2% lidocaine) 5 • Complications commonly associated with thoracentesis • One small needle (25-gauge, 8 -inch long) include: pneumothorax, hemopneumothorax, hemorrhage, • 5-mL syringe for local anesthetic

222 28 Thoracentesis (Assist) 223

1 • Three large needles (20- to 22-gauge, 1 2 to 2 inches long) • Assess for signs and symptoms of pleural effusion. Ratio- • Three-way stopcock nale: Physical fi ndings may suggest a pleural effusion. • Sterile 20-mL syringe ❖ Trachea deviated away from the affected side • Sterile 50-mL syringe ❖ Affected side dull to fl at with percussion • Two chemistry blood tubes ❖ Absent or decreased breath sounds • Hemostat or Kelly clamp ❖ Tactile fremitus • Pulse oximetry equipment ❖ Pleuritic chest pain • Side table ❖ Hypoxemia • Pillow or blanket to be placed on side table ❖ Tachypnea • 14-gauge needle ❖ Dyspnea • 16-gauge catheter ❖ Cough, weight loss, night sweats, anorexia, and malaise • Vacutainers or evacuated bottles (1 to 2 L) with pressure may also occur with pleural infection or malignancy tubing disease Additional equipment, to have available as needed, includes • Anterior-posterior chest radiographs completed in the the following: intensive-care setting are typically completed in the supine • Atropine, oxygen, thoracostomy supplies, advanced position and are less sensitive in the identifi cation of cardiac life-support equipment pleural effusions. In this setting, hazy opacifi cation of one • Ultrasound-scan equipment as available and with a cre- lung fi eld or minor fi ssure thickening may be the only dentialed provider clues to the presence of a pleural effusion.10 Rationale: In • Two complete blood count tubes the supine position, pleural effusions tend to spread out • One anaerobic and one aerobic media bottle for culture across the posterior thoracic surface and are less evident and sensitivity on supine radiographs. • Sterile tubes for fungal and tuberculosis cultures specimen • Assess baseline vital signs, including pulse oximetry. tubes Rationale: Baseline assessment data provide information • Commercially prepackaged thoracentesis kits which are about patient status and allow for comparison during and available in some institutions after the procedure. • Assess recent serum laboratory results, including the fol- PATIENT AND FAMILY EDUCATION lowing. Rationale: These studies help determine whether the patient is at risk for bleeding. Although thoracentesis is • Assess patient ’ s and family ’ s level of understanding about considered to have a low risk of bleeding, an international the condition and rationale for the procedure. Rationale: normalized ratio of 1.5 or less is acceptable for invasive This assessment identifi es the patient ’ s and family ’ s procedures.5,11 Platelet transfusion is recommended for knowledge defi cits concerning the patient’ s condition, the counts < 50,000. No consensus/recommendations exist for procedure, the expected benefi ts, and the potential risks. partial thromboplastin time and hematocrit thresholds. It also allows time for questions to clarify information and There is no evidence to support the use of bleeding times voice concerns. Explanations decrease patient anxiety and before minimally invasive procedures.11 enhance cooperation. ❖ Hematocrit • Explain the procedure and the reason for the procedure, if ❖ Platelet count the clinical situation permits. If not, explain the procedure ❖ Prothrombin time/international normalized ratio and reason for the intubation after it is completed. Ratio- ❖ Partial thromboplastin time nale: This explanation enhances patient and family under- standing and decreases anxiety. Patient Preparation • Explain the patient ’ s role in thoracentesis. Rationale: • Verify that the patient is the correct patient using two This explanation increases patient compliance, facilitates identifi ers. Rationale: Before performing a procedure, needle and catheter insertion, and enhances fl uid removal. the nurse should ensure a timeout was completed to verify the correct identifi cation of the patient for the intended intervention. PATIENT ASSESSMENT AND • Ensure that the patient understands preprocedural teach- PREPARATION ings. Answer questions as they arise and reinforce infor- mation. Rationale: This communication evaluates and Patient Assessment reinforces understanding of previously taught information. • Assess medical history of symptoms, occupational expo- • Ensure written informed consent for the procedure has sure, pleuritic chest pain, malignancy disease, heart failure, been completed. Rationale: Invasive procedures, unless and medication usage. Rationale: Medical history may performed with implied consent in a life-threatening situ- provide valuable clues to the cause of a patient’ s pleural ation, require written consent of the patient or signifi cant effusion or presence of hypercoagulable states as a result other. of medications. Knowledge of medication usage can indi- • Assist with patient positioning. Several alternative posi- cate the need for anticoagulation reversal. In addition, an tions may be used, as follows. Rationale: Positioning increasing number of medications are noted to contribute enhances patient comfort and ease of pleural fl uid to exudative effusions. See http://www.pneumotox.com .9 withdraw. 224 Unit I Pulmonary System

❖ On the edge of the bed with legs supported and arms • Inquire about the need for sedation or paralysis. Ratio- resting on a pillow on the elevated bedside table (see nale: Sedation or paralysis may be necessary to maximize Fig. 27-1 ). positioning. ❖ Backwards on a chair with arms resting on a pillow • Have atropine available. Rationale: Bradycardia, from a over the chair back. vasovagal refl ex, is not uncommon during thoracentesis. • If the patient is unable to sit, position the patient on the • Initiate pulse oximetry monitoring. Rationale: Pulse unaffected side, with his or her back near the edge of the oximetry provides a noninvasive means for monitoring bed and the arm on the affected side above the head. oxygenation and heart rate at the bedside, which allows Elevate the head of the bed to 30 or 45 degrees, as toler- for prompt recognition and intervention should problems ated. Position yourself or another member of the health- develop. care team in front of the patient. Rationale: This • Ensure patent IV access. Rationale: Provides IV access positioning enables visualization of facial cues and a close for both procedural and emergency medications, as proximity to reassure or comfort the patient. necessary

Procedure for Assisting with Diagnostic and Therapeutic Thoracentesis Steps Rationale Special Considerations 1 . HH 2 . PE 3. Assemble equipment and Ensures proper equipment is readily procedure tray. available throughout procedure and in emergency situations. 4. Assist with patient positioning. Positioning that optimizes patient comfort aids in patient cooperation and completion of the procedure. 5. Assume a position in front of Positioning in front of the patient the patient and provide physical ensures visualization of facial cues support for positioning, as and enables the cessation of necessary. inadvertent patient movements that might interfere with the procedure. 6. As directed by physician or Premedication with opioid, advanced practice provider, antianxiolytic, sedative, or administer procedural hypnotic ensures patient comfort medications. throughout procedure. 7. Throughout procedure, assist The physician or advanced practice with providing continuous provider is focused on the monitoring of patient vital signs technique required to obtain the and response to the procedure fl uid and may be delayed in and interventions. noticing patient changes. 8. As directed by physician or Analysis may aid in determining an To interpret pleural fl uid laboratory advanced practice provider, etiology of the pleural effusion. values, serum chemistry laboratory assist with fi lling of the values must be obtained (e.g., pH, specimen tubes from the pleural total protein, glucose, and lactate fl uid–fi lled syringe. Label dehydrogenase). appropriately and send the specimen tubes to the laboratory for appropriate analysis. 9. As directed by physician or The vacutainer or evacuated bottles Evacuating more than 1000–1500 mL advanced practice provider, use negative pressure to withdraw of pleural fl uid at one time may assist with attaching the pleural fl uid from the pleural cause hypovolemia, hypoxemia, or vacutainer or evacuated bottles space, providing therapeutic relief. reexpansion pulmonary edema. with tubing to the three-way Assist in repositioning the patient The patient may feel the need to stopcock. if drainage stops, as directed. cough as the lung reexpands. 28 Thoracentesis (Assist) 225

Procedure for Assisting with Diagnostic and Therapeutic Thoracentesis—Continued Steps Rationale Special Considerations 10. On completion of thoracentesis, Without concrete clinical indications, the physician or advanced chest radiograph is not necessary practice provider may apply after a routine thoracentesis. pressure to the puncture site for a few minutes. After pressure application has been completed, apply an adhesive bandage over the puncture site. 11. Reposition patient to optimize Patient may desire to lie down after comfort. procedure completion. Head-of-bed placement may vary if dyspnea, hypotension, or other symptoms are present during procedure. 12. Dispose of soiled supplies and remove personal PE . 13. HH

Expected Outcomes Unexpected Outcomes • Patient is comfortable and has decreased respiratory • Pneumothorax distress • Vasovagal response • Lung reexpansion occurs • Dyspnea • Site remains infection free • Hypovolemia • Procedure aids in diagnosing of etiology of pleural • Hematoma effusion • Hemothorax • Liver or splenic laceration • Reexpansion pulmonary edema

Patient Monitoring and Care Steps Rationale Reportable Conditions These conditions should be reported if they persist despite nursing interventions. 1. Monitor vital signs and Any change in vital signs may • Tachypnea cardiopulmonary status before, alert the practitioner of possible • Decreased or absent breath sounds during, and after thoracentesis. unexpected outcomes. Use of on the affected side supplemental oxygen may be • Shortness of breath, dyspnea necessary. • Asymmetrical chest excursion with respirations • Decreased oxygen saturation • Subcutaneous emphysema • Sudden sharp chest pain • Anxiety, restlessness, apprehension • Tachycardia • Hypotension • Dysrhythmias • Tracheal deviation to the unaffected side • Neck vein distention • Muffl ed heart sounds Procedure continues on following page 226 Unit I Pulmonary System

Patient Monitoring and Care —Continued Steps Rationale Reportable Conditions 2. If indicated, obtain a A chest radiograph is used to • Pneumothorax postthoracentesis expiratory evaluate for lung reexpansion • Catheter migration chest radiograph. (Level C * ) and evidence of a possible • Expanding pleural effusion pneumothorax or hemothorax. If a pneumothorax or hemothorax is present, a chest tube may be necessary. Without concrete clinical indications, chest radiograph is not necessary after a routine thoracentesis.2,3,5 3. Follow institution standard for Identifi es need for pain • Continued pain despite pain assessing pain. Administer interventions. interventions analgesia as prescribed.

* Level C: Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results.

Documentation Documentation should include the following: • Patient and family teaching • Total amount of pleural fl uid aspirated • Presence of completed consent for procedure • Site assessment • Adherence to Universal Protocol • Occurrence of unexpected outcomes • Patient positioning and monitoring devices • Postthoracentesis radiograph acquisition and results, • Medication administration and patient response as needed/available • Patient tolerance, including procedural pain and • Laboratory test ordered and results, as available instillation and response to pain medications • Nursing interventions • Pleural fl uid aspirate characteristics • Pain assessment, interventions, and effectiveness

References and Additional Readings For a complete list of references and additional readings for this procedure, scan this QR code with any freely available smartphone code reader app, or visit http://booksite.elsevier.com/9780323376624 .