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27 Thoracentesis (Perform) 213 PROCEDURE Thoracentesis (Perform) 27 Susan Yeager PURPOSE: Thoracentesis is performed to assist in the diagnosis and therapeutic management of patients with pleural effusions. PREREQUISITE NURSING do not establish a diagnosis; instead the laboratory results KNOWLEDGE must be correlated with the clinical fi ndings and serum laboratory results. • Thoracentesis is performed with insertion of a needle or • Light ’ s criteria should be used to distinguish between a a catheter into the pleural space, which allows for removal pleural fl uid exudate and transudate. In order to apply of pleural fl uid. Light ’ s criteria, the total protein and lactate dehydroge- • Pleural effusions are defi ned as the accumulation of nase (LDH) should be measured in both blood and pleural fl uid in the pleural space that exceeds 10 mL and results fl uid ( Box 27-1 ). 2,3 from the overproduction of fl uid or disruption in fl uid • Exudative effusions indicate a local etiology (e.g., pulmo- reabsorption. 1 nary embolus, infection), whereas transudative effusions • Thoracentesis is not used to verify the presence of pleural usually are associated with systemic etiologies (e.g., heart effusion. Diagnosis of pleural effusion is made via clinical failure). 3 examination, patient symptoms, and diagnostic tech- • Exudative pleural effusions meet one of the following niques. A number of techniques can demonstrate pleural criteria: effusion with varying levels of sensitivity. Percussion ❖ Pleural fl uid LDH/serum LDH ratio is greater than 0.6 requires a minimum of 300 to 400 mL for identifi cation international units/mL. of a pleural effusion, whereas a standard chest radiogra- ❖ Pleural fl uid LDH is more than two thirds of the upper phy requires 200 to 300 mL. Lateral decubitus radio- limit of normal for serum LDH. graphs can be used to recognize smaller fl uid amounts and ❖ Pleural fl uid protein/serum protein ratio is greater than highlight whether present fl uid is free fl owing. Ultrasound 0.5 g/dL. 3 scan, computed tomography (CT) scan, and magnetic • Relative contraindications for thoracentesis include the resonance imaging (MRI) technology can detect 100 mL following: 1 of fl uid with 100% sensitivity. Therefore, initial diagnosis ❖ Patient anatomy that hinders the practitioner from of pleural effusion may be optimized via imaging tech- clearly identifying the appropriate landmarks niques such as chest radiographs, ultrasound scans, CT ❖ Patients actively undergoing anticoagulation therapy or scans, or MRI combined with patient symptoms and clini- with an uncorrectable coagulation disorder cal examination fi ndings. ❖ Patients receiving positive end-expiratory pressure • Diagnostic thoracentesis is indicated for differential diag- therapy nosis for patients with pleural effusion of unknown etiol- ❖ Patients with splenomegaly, elevated left hemidia- ogy. A diagnostic thoracentesis may be repeated if initial phragm, or left-sided pleural effusion results fail to yield a diagnosis. ❖ Patients with only one lung as a result of a previous • Therapeutic thoracentesis is indicated to relieve the symp- pneumonectomy toms (e.g., dyspnea, cough, hypoxemia, or chest pain) ❖ Patients with known lung disease caused by a pleural effusion. ❖ Patients with active skin infection at the point of needle • Pleural effusions are classifi ed as either transudative or insertion 4 exudative effusions. • Ultrasound scan–guided thoracentesis is thought to reduce • Samples of pleural fl uid are analyzed and assist in distin- complications. guishing between exudative and transudative etiologies of • Complications commonly associated with thoracentesis effusion. Results of laboratory tests on pleural fl uid alone include pneumothorax, hemopneumothorax, hemorrhage, hypotension, cough, pain, visceral injury, and reexpansion pulmonary edema. 4–6 • The most common complications from pleural aspiration are pneumothorax, pain, hemorrhage, and procedure This procedure should be performed only by physicians, advanced 5 practice nurses, and other healthcare professionals (including critical care failure. The most serious complication is visceral injury. nurses) with additional knowledge, skills, and demonstrated competence per • Hypotension can occur as part of the vasovagal reaction, professional licensure or institutional standard. causing bradycardia, during or hours after the procedure. 211 212 Unit I Pulmonary System • Three-way stopcock BOX 27-1 Light ’ s Criteria for Exudative • Sterile 20-mL syringe Pleural Effusions (Applies If • Sterile 50-mL syringe One or More Criteria Are Met) • Two chemistry blood tubes EXUDATIVE CRITERIA • Hemostat or Kelly clamp Ratio of pleural fl uid protein to serum protein is > 0.5 • Pulse oximetry equipment Ratio of pleural fl uid lactate dehydrogenase (LDH) to serum LDH • Side table is > 0.6 • Pillow or blanket to be placed on side table 2 Pleural fl uid LDH level is > 3 of the upper limit of normal for • 14-gauge needle serum LDH • 16-gauge catheter • Vacutainers or evacuated bottles (1 to 2 L) with pressure Modifi ed from Porcel J, Light R: Diagnostic approach to pleural effusion in tubing adults, Am Fam Physician 73(7):1211–1220, 2006. Additional equipment, to have available as needed, includes the following: • Atropine, oxygen, thoracostomy supplies, advanced cardiac life-support equipment If it occurs during the procedure, cessation of the proce- • Ultrasound-scan equipment as available and with a cre- dure and intravenous (IV) atropine may be necessary. If dentialed provider hypotension occurs after the procedure, it is likely the • Two complete blood count tubes result of fl uid shifting from pleural effusion reaccumula- • One anaerobic and one aerobic media bottle for culture tion. In this situation, the patient is likely to respond to and sensitivity fl uid resuscitation. 7 • Sterile tubes for fungal and tuberculosis cultures specimen • Development of cough generally initiates toward the tubes end of the procedure and should result in procedure • Commercially prepackaged thoracentesis kits, which are cessation. available in some institutions • Reexpansion pulmonary edema is thought to occur from overdraining of fl uid too quickly. The incidence is less PATIENT AND FAMILY EDUCATION than 1% but asymptomatic radiologically apparent reper- fusion pulmonary edema may be slightly more frequent. 5 • Assess patient ’ s and family ’ s level of understanding about The maximum volume of fl uid that can be safely removed the condition and rationale for the procedure. Rationale: is uncertain because the volume removed does not clearly This assessment identifi es the patient ’ s and family ’ s correlate with the onset of symptoms. Traditionally, to knowledge defi cits concerning the patient ’ s condition, the avoid this complication, discontinuation of fl uid removal procedure, the expected benefi ts, and the potential risks. occurs with the onset of symptoms or when the total fl uid It also allows time for questions to clarify information and removed reaches 1000 to 1500 mL. 5,6 voice concerns. Explanations decrease patient anxiety and • If using continuous positive airway pressure, caution enhance cooperation. should be taken to avoid potential pneumothorax follow- • Explain the procedure and the reason for the procedure, if ing aspiration if there is no pleural drain in place. 5 Patients the clinical situation permits. If not, explain the procedure receiving positive airway pressure can undergo thoracen- and reason for the intubation after it is completed. Ratio- tesis with an ultrasound-guided incidence of less than 7% nale: This explanation enhances patient and family under- pneumothorax noted. 4,8 standing and decreases anxiety. • Baseline diagnostic study results (i.e., lateral decubitus • Explain the patient ’ s role in thoracentesis. Rationale: chest radiograph, ultrasound imaging, CT scan, or MRI) This explanation increases patient compliance, facilitates should be reviewed before the procedure to identify the needle and catheter insertion, and enhances fl uid removal. location and extent of pleural fl uid accumulation. EQUIPMENT PATIENT ASSESSMENT AND PREPARATION • Indelible marker • Sterile gloves Patient Assessment • Sterile drapes • Assess medical history of symptoms, occupational expo- • Sterile towels sure, pleuritic chest pain, malignancy disease, heart • Adhesive bandage or adhesive strip failure, and medication usage. Rationale: Medical history • Antiseptic solution may provide valuable clues to the cause of a patient ’ s • Sterile 4 × 4 gauze pads pleural effusion or presence of hypercoagulable states • Intervention medications (opioid, sedative, or hypnotic as a result of medications. Knowledge of medication agents, local anesthetic 1% or 2% lidocaine) usage can indicate the need for anticoagulation reversal. 5 • One small needle (25-gauge, 8 -inch long) In addition, an increasing number of medications are • 5-mL syringe for local anesthetic noted to contribute to exudative effusions. See http:// 1 9 • Three large needles (20- to 22-gauge, 1 2 to 2 inches long) www.pneumotox.com . 27 Thoracentesis (Perform) 213 • Assess for signs and symptoms of pleural effusion. or if initial tube drainage is unsuccessful and surgery is to Rationale: Physical fi ndings may suggest a pleural be considered. 2 effusion. • Assess baseline vital signs, including pulse oximetry. ❖ Trachea deviated away from the affected side Rationale: Baseline assessment data provide information ❖ Affected side dull to fl at with percussion about patient status and allow for comparison during and ❖ Absent
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