Pleural fluid aspiration [advanced]

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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)

• 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:
  • 5^th 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 (5^th 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

A patient presents to ED with chest pain and this trace. What would you do?

Interpretation management

Covered in OSCE Stations

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