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Pleural fluid aspiration [advanced]

Before you start

Indications: to aid in the diagnosis of the cause of a pleural effusion (not a therapeutic procedure)

Contraindications: coagulopathy (INR >1.4, platelets <50, therapeutic anticoagulant <24 hours, clopidogrel <7days)

Introduction

  • Wash hands, Introduce self, Patients name & DOB & wrist band, Explain procedure and get written consent
    • Risks: pain; bleeding; infection; organ puncture & damage (lung, heart, liver); persistent site leak; pneumothorax
  • **Check patients clotting screen, platelet count and if they have been on an therapeutic anticoagulant/clopidogrel**
  • Ensure assistant is available
  • Confirm the correct side to aspirate (3 point check)
    • Review chest X-ray
    • Examine patient’s chest
    • Confirm position and size with portable ultrasound scanner

Preparation part

  • Wash hands and apply apron
  • Clean  a trolley
  • Gather equipment onto bottom of trolley (think through what you need in order)
    • Sterile pack
    • Cleansing snap-sponge (iodine or alcohol/chlorhexidine) x2
    • OPTIONAL: Sterile drape with hole in centre (or 2-3 drapes without holes in)
    • 10ml syringe and 3 needles (1 blunt fill 18G drawing-up needle, 1 orange 25G, 1 green 21G) for local anaesthetic
    • For pleural fluid aspiration
      • Green 21G needle
      • 50ml syringe
    • Cotton gauze swabs (used whenever needed throughout procedure to dry/clean sterile area)
    • Sterile dressing
    • Equipment to be kept outside of the sterile field
      • Portable ultrasound scanner (± sterile probe cover and gel if you want to re-scan after sterilising)
      • Sterile gloves
      • 10ml 1% lidocaine (maximum 3mg/kg – note 1ml 1% lidocaine = 10mg)
      • 2-4 white-topped sample collection bottles ± blood culture bottles
  • Walk to patient
  • Wash hands
  • Open sterile pack to form a sterile field on the top of the trolley
  • Open packets (without touching the instruments themselves) and drop sterile instruments neatly into the sterile field
  • Pick up waste bag from sterile pack without touching anything else and stick to side of trolley

Patient part

Positioning and exposure

  • Expose patient’s chest
  • Position patient sitting on chair or edge of bed with raised arms (crossed arms leaning on a bedside table or hands on head)
  • Locate insertion point:
    • 5th intercostal space, mid-axillary line
    • Within the safe triangle formed by
      • Anterior border of latissimus dorsi
      • Lateral border of pectoralis major
      • Horizontal line from the nipple (5th intercostal space)
    • Just above a rib (to avoid neurovascular bundle)
  • Use different site if there is overlying infection
  • Confirm effusion is present at proposed entry site using portable ultrasound scanner (different sites may be used if there is more fluid elsewhere)
  • Mark insertion point with a skin pen/indentation

Preparation

  • Wash hands
  • Apply sterile gloves using sterile technique (open pack on a side surface)
  • Sterilize area
    • Work from middle outwards in one spiral motion (using cleansing snap-sponge)
    • Repeat with second cleansing snap-sponge
    • Discard used snap-sponges as they are no longer sterile, but note all equipment used after this (including all needles) can be returned to the sterile field after use
    • OPTIONAL: Apply the sterile drape over the patient’s body so that the hole is in the correct place to allow access to the insertion site (or apply 2-3 drapes centred around exposed insertion site if no holes)
  • Anaesthetise tract
    • Ask assistant to snap open lidocaine bottle and hold open upside-down
    • Draw up lidocaine using drawing-up needle on 10 ml syringe and expel any air
    • Change to the orange needle and insert at an acute angle to form a single subcutaneous bleb around insertion site in order to anaesthetise the skin
    • Change to the green needle and insert perpendicular to the skin to anaesthetise the insertion tract
      • This is done by instilling lidocaine in small increments of increasing depth – only anaesthetise the intercostal muscles and pleura (the fat inbetween has no nerves)
      • Always aspirate when advancing the needle (so you know when you get to the pleural cavity) and aspirate before injecting lidocaine (to check you are not in a vessel)
      • When fluid (from pleural cavity) is aspirated, note entry depth, then withdraw the needle
      • DO NOT PROCEED if you do not get an aspirate!
    • Wait 1 minute to work

Pleural aspiration

  • With 50ml syringe on a new green needle, insert perpendicular to the skin into the insertion tract
  • Aspirate during infiltration
  • As soon as fluid is aspirated, stop advancing the needle and aspirate 50ml (or as much as possible)
  • Withdraw the needle

Finally

  • Dress wound

To complete

  • Thank patient and cover them
  • Bin waste and gloves, dispose of sharps safely in sharps bin, clean trolley and wash hands
  • Label sample tubes and send to lab:
    • MC&S (blood culture bottles or white-top x2) → microbiology
    • Protein, glucose and LDH (white-top) → biochemistry
    • Cytology (white top) → histopathology
    • pH analysis (1ml left in syringe) → run manually on approved blood gas machine
    • Other tests to consider: amylase (pancreatitis), Ziehl-Neelsen stain (TB), haematocrit (if bloody effusion), triglycerides/cholesterol/chylomicrons (chylothorax), rheumatoid factor/complement (rheumatic disease)
  • Perform venepuncture to determine concurrent blood glucose, serum protein and LDH level (very important for interpretation)
  • Fully document procedure in patients notes
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