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 insertion 4 • 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 11 voice concerns. Explanations decrease patient anxiety and before minimally invasive procedures. 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