Thoracentesis (pleural puncture)

Thoracentesis (pleural puncture) is to insert the needle into the pleural cavity, indicated for diagnosis (explorer) or therapeutic.
Diagnostic indications:
– The existence of pleural fluid collections of clinical (chest dullness to abolish the vocal vibrations and murmur in the area) and identify the nature of radiological → effusion.
Indications:
– Evacuation of

large pleural collections: hydrothorax (heart failure), posttraumatic massive hematoma, pleural serofibrinoasa abundance unresolved medical, purulent pleurisy;
– Introduction topical medicinal substances (antibiotics, chemotherapy).
Contraindications paramediastinale or paravertebral encysted collections (see differential diagnosis of aortic aneurysms or cold abscesses osifluente).
– Mechanically ventilated traumatic pneumothorax – pneumothorax risk of transformation in valve and bronchopleural fistula
– Suspicion of aneurysm of the aorta,
– Coexistence of a cold abscess osifluent

Materials needed:
– Antiseptics: Alcohol iodine, betadine
– Buffers and porttampon (Pension)
– Syringes, needles or trocars sterile, disposable
– Anesthetic (lidocaine) 1-2%, atropină1%
– Sterile gloves
– 3-way valve
– Sterile tubes for bacteriological examinations
– Tubes with anticoagulant, heparin-for cytological and biochemical examinations
– Suction device,
– Drainage tubes, bottle collector
– Sterile bandage compresses
Place of points:
– If available collections of pleura → VIII intercostal space puncture in the posterior axillary line;
– If encysted collections → matitatii puncture in the center, avoiding trails that infringe certain anatomical formations;
– If compressive pneumothorax (smothering valve in blood) → puncture followed by pleurostomie II intercostal space medioclaviculara line;
– In case of hemopneumothorax → next point pleurostomie VI intercostal space on the posterior axillary line medium;
– Avoid heart region, the top portion armpit and chest under the ribs IX (risk of leakage into the peritoneum).

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Patient Preparation
– Physically and mentally: Explanation patient medical gesture to be performed, its rationale, the expected benefits, possible risks, and medical measures to minimize it. Maneuver will not be involuntary.
– Before the puncture will be chest radiography and is beneficial to determine TS, TC and the patient’s blood group

– Premedication:
 codeine administered one hour before to prevent cough
 atropine 1% SC administered 20-30 minutes prior to pleural puncture to avoid vagal shock in the absence of contraindications (glaucoma or periurethral adenoma with chronic retention of urine)
 We are receiving medication or opiate-benzodiazepine sedative-risk due to respiratory distress, especially in the elderly
Position the patient:
– Classic: sick sitting on the bed with chest and elbows slightly bent above the knee supported (maximum opening intercostal spaces), supported helpful in this position;
– Seated astride the seat, facing the back of it, his arms resting on the backrest or arm raised above his head punctured hemithorax
– Seated on a chair, the side with the healthy side towards the back of it, with the healthy arm supported on the back and the other arm raised above his head, putting into evidence the preferred site of puncture.
– Pneumothorax “valve” encysted collections before or side: patient supine or lateral.
– If the patient can not maintain a sitting position pleural puncture can be performed in the lateral decubitus healthy back to the operator and the sick arm raised above his head.
– Regardless of position, lifting arm and sleep at the end of a deep inspiration when the puncture causes enlargement of intercostal spaces, facilitating execution of the maneuver.
– The duration of the maneuver, a nurse will be placed in front of the patient, monitoring it

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Proper technique:
– Disinfection of the area with tincture of iodine;
– Anesthesia layer by layer (including pleura);
– 10-15 minutes installing efectului.Pentru expect most patients achieving anesthesia is unnecessary if the puncture needle puncture is made with ordinary
– Index tracking the tip of the upper edge of the coast that separates the lower intercostal space respectively;
– Needle fitted to the syringe, or a 3-way valve interposed between the needle and syringe (if desired discharge fluid collection), it suddenly penetrates perpendicularly through the skin, laughing with the upper edge of the coast, is then cross the intercostal muscles ( I 3 cm thick) endotoracica fascia and parietal pleura;
– Aspiration of fluid from 0.20 to 30 ml for analysis of biochemical, bacteriological, cytological;
– If therapeutic puncture evacuatorii: attachment to the needle or trocar puncture through robinetuluicu after closing his three horses, a drainage tube connected to a collection container (drainage type Becla, with the distal end of the drainage tube placed in the container collection as a liquid level to prevent iatrogenic pneumothorax occurrence), possibly suction drainage;
– Will evacuate 1,500 ml of pleural fluid within a therapeutic session.
– Closing the tap and needle retraction, massaging the puncture site with alcohol swab, sterile dressing.
– Tubes with fluid collected, labeled corspunzător will be transported to the laboratory
– Remove materials used subject PU

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intercostal vascular-nervous bundle: vein, artery, nerve (top to bottom)
Patient observation after puncture
In the following hours the patient will be monitored pleural puncture urmarindu.se possible occurrence of cough, chest pain, breathlessness, sweating, tachycardia, thirst, or hypotension. After puncture means repeat chest radiograph. This is mandatory if signs mentioned (suspected pneumothorax or pleural effusion enlargement)
Complications of pleural puncture
Incidents:
– Damage to a vessel subcostal package with needle drainage of blood, living irradiated intercostal pain, hematoma of the wall → withdrawing the needle, local compression;
– Punctured lung with blood leaking aerated → withdrawal of the needle;
– Sudden stop jet (obliteration of the lung needle or false membranes) which shows almost complete evacuation of fluid or obstruction of the lumen of the needle through a biological fragment → mobilization needle dezobstructie with Mandrel, if suspected an encysted pleurisy with cloazonări, after reinspection will be repeated radiological point to the other intercostal space
– Point “white” → possible repeat ultrasound guided.
– Cough occurs relatively frequently and requires handling the needle off, its easy withdrawal and / or intermittent cough precedes the discharge pleurale.Uneori installation vagal syncope.
Accidents:
– Acute pulmonary edema (too rapid evacuation, evacuation of more than 1200 ml liquid) with dyspnea, cyanosis, cough, frothy sputum rozata, crepitation rales “in waves” insuficinta signs of heart, due to the rapid evacuation of too much liquid in one sitting, those with chronic large fluid collections → glycosides, oxygen;
– Vagal syncope (by reflex vagal pleural starting point) manifested reflex bradycardia, hypotension, loss of consciousness → interruption followed by thoracentesis, CPR;
– Pneumothorax may result from damage to the lung or pleura air penetration through the lumen of the needle puncture or drainage suction drainage type → Becla;
– Hemototax secondary damage intercostal vessels, pleural hemorrhage
– Internal bleeding with hemorrhagic shock secondary liver or spleen damage with haemoperitoneum intraparenchymal haemorrhage or encapsulation, where the point was made too audibly without fluoroscopic guidance
– Infection of pleural effusion (purulent pleurisy transformation) due to non-aseptic rules → drain pus, antibiotics.

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