Thoracocentesis: indications and technique. Thoracocentesis (pleural puncture)

Indications. Pleural effusion unclear etiology, detected by X-ray, is the most frequent indication for pleural puncture; it is especially necessary if an exudative effusion is suspected. Patients with transudates usually do not undergo thoracocentesis, except in cases of suspicious effusion, when it is necessary to make sure that there are no reasons for its appearance other than an increase in hydrostatic pressure or a decrease in oncotic pressure. Thoracocentesis is indicated for infections of unknown origin or failure antimicrobial therapy. It is rarely needed for simple parapneumonic effusions if the patient is improving. Analysis of pleural effusion is important in diagnosing and staging suspected or known malignant process, as well as at unusual reasons the appearance of fluid in the pleural cavity (for example, hemothorax, chylothorax, or empyema), since in these cases, as a rule, additional invasive treatment is required. Sometimes it is necessary to investigate the effusion that occurs when systemic diseases(for example, with collagenoses).

Therapeutic indications. Thoracocentesis is used to eliminate respiratory failure caused by massive pleural effusion, as well as for the introduction of antitumor or sclerosing agents into the pleural cavity (after removal of the effusion). Most doctors prefer to use thoracostomy tubes in the latter case.

Technique. Thoracocentesis can be performed at various sites chest depending on the indication (see the terms Drainage of the pleural cavity, "Thoracotomy"). If it is necessary to perform thoracocentesis of the lateral wall of the chest, the patient is placed on healthy half, under which a roller is placed so that the intercostal spaces move apart, if in the II-III intercostal space in front - on the back. When diagnosing respiratory failure, thoracocentesis should be performed with the patient half-sitting.

After processing operating field(within a radius of at least 10 cm) 0.25-0.5% solution of novocaine is produced local anesthesia skin along the projection of the intercostal space, and with a longer needle - anesthesia subcutaneous tissue, muscles. The advancement of the needle further should be accompanied by the continuous injection of novocaine solution. When the pleura is pierced, pain will appear. To clarify the location of the needle in the pleural cavity, pull the syringe plunger towards you - the entry of air or other contents into the syringe indicates that the needle has entered the pleural cavity. After that, the needle is slightly removed from the pleural cavity (for anesthesia of the parietal pleura) and 20-40 ml of novocaine solution is injected. Then the needle, connected to the syringe, slowly and perpendicularly chest cavity advance into the pleural cavity, continuously bringing the plunger of the syringe towards itself.

The flow of fluid or air from the pleural cavity into the syringe allows you to characterize the depth of the free pleural cavity, to which it is safe to insert a trocar or clamp without fear of hurting internal organs. Having calculated the depth of the free pleural cavity by this method, the SKIN is cut and pushed apart soft tissues and insert a trocar or clamp into the pleural cavity, depending on the purpose of the thoracocentesis. If, after this manipulation, drainage is introduced into the pleural cavity, the latter is fixed with a U-shaped suture, the ends of the thread are tied with a bow. This is done so that after removal of the drainage, it is possible to tighten the knot and close the wound without violating the tightness of the pleural cavity. If drainage is not introduced, the wound is sutured with 1-2 sutures, after which an aseptic dressing is applied.

This study is used in real time to facilitate anesthesia, and then the needle is placed.

Thoracocentesis is indicated for the symptomatic treatment of large pleural effusions or for the treatment of empyema. Also, the procedure is necessary for pleural effusions of any size that require diagnostic analysis.

Transudate effusions are due to decreased plasma and result from decreased plasma oncotic pressure and increased hydrostatic pressure. Heart failure is the most common cause, followed by cirrhosis of the liver and nephrotic syndrome.
Exudate effusions result from local destructive or surgical processes, which cause increased capillary permeability and subsequent exudate of intravascular components to potential sites of disease localization. Causes are varied and include pneumonia, dry pleurisy, cancer, pulmonary embolism and numerous infectious etiologies.

There are no absolute contraindications for thoracocentesis.

Relative contraindications include the following:

Uncorrected bleeding diathesis.
Cellulitis of the chest wall at the puncture site.
Patient disagreement.

Attention

Before performing a thoracocentesis, it is important to pay attention to the patient's consent and his hopes for the procedure, as well as possible risks and complications.

Consent for thoracocentesis must be obtained from the patient or family member. You need to make sure they have an understanding about the procedure so they can make an informed decision.

The patient should be warned about the following risks from thoracocentesis:

pneumothorax;
hemothorax;
lung rupture;
infection;
empyema;
intercostal damage;
intrathoracic injuries related to the diaphragm, puncture of the liver or spleen;
damage to other organs of the abdominal cavity;
hemorrhages in the abdominal cavity;
pulmonary edema from a catheter fragment left in the pleural space.

Before the thoracocentesis procedure, it is necessary to analyze which of the above risks can be avoided or prevented (for example, the position of the patient in which he remains as still as possible during the procedure).

Thoracentesis Kit: Basic Materials List

There are several special medical devices specially designed for performing the thoracocentesis procedure.

Assortment of GRENA thoracocentesis kits (Great Britain)

Thoracocentesis / paracentesis set 01SN

– Syringe Luer Lock 60 m

Thoracocentesis / paracentesis set 02SN

– Puncture needle - 3 pcs.

– Connecting tube with Luer Lock ports at the ends.

– 2 liter graduated bag with drain.

– Syringe Luer Lock 60 m

Thoracocentesis / paracentesis set 01VN

– Connecting tube with Luer Lock ports at the ends.

– 2 liter graduated bag with drain.

– Syringe Luer Lock 60 m

– Connecting tube with Luer Lock ports at the ends.

Thoracocentesis: technique for performing the main procedure and drainage of the pleural cavity

Preparation for the procedure includes appropriate anesthesia and proper positioning of the patient's body.
In addition to local anesthesia, it may also be considered general anesthesia lorazepam, which will help to cope with any manifestations of pain.

In thoracocentesis, pain medication is critical important components, as complications may develop in its absence. Local anesthesia is achieved with lidocaine.

Important

The skin, subcutaneous tissue, rib, intercostal muscle and parietal pleura should be well saturated with local anesthetic. It is especially important to anesthetize the deep part of the intercostal muscle and the parietal pleura, because the puncture of these tissues is accompanied by the most acute pain.

Pleural fluid is often obtained through anesthetic penetration into more deep structures which will help determine the location of the needle.

The most favorable position of patients for thoracocentesis is sitting, leaning forward, the head lies on the hands or on a pillow, which is located on a special table. This position of the patient facilitates access to the axillary space. Patients who are unable to be in this position, take the horizontal on the back.

A towel roll is placed under the contralateral shoulder (where the procedure will be performed) so that the thoracocentesis drains the pleural density successfully and allows access to the next axillary space.

Technique for performing thoracocentesis

Ultrasonography. After the patient has been seated, ultrasonography is performed to confirm the pleural effusion, assess its size and location. Next, determine the most optimal puncture site. For ultrasonography, either a curvilinear transducer (2-5 MHz) or a high-frequency linear transducer (7.5-1 MHz) is used. Aperture must be explicitly defined. It is important to choose an intercostal interval in which the diaphragm will not rise on exhalation.
Open way. In this type, ultrasonography is used to determine the depth of the lung and the amount of fluid between the chest wall and the inner pleura. A free-floating lung may be marked as a wave.

Ultrasonography is a useful study for thoracocentesis, which helps determine the optimal puncture site, improves the localization of local anesthetics, and, most importantly, minimizes complications of the procedure.

The optimal puncture site can be determined by searching for the big pocket fluid, superficial to lung, defining airway diaphragm. Traditionally, given area located between the 7th and 9th ribs.

Diagnostic analysis of pleural fluid

The pleural fluid is labeled and sent to diagnostic analysis. If the effusion is small and contains a large number of blood, the liquid is placed in a blood tube with an anticoagulant so that this mixture does not thicken.

The following laboratory tests should show the following points:

pH level;
gram color;
cell count and differential;
glucose levels, protein levels and lactic acid dehydrogenase (LDH);
cytology;
creatinine level;
amylase level if esophageal perforation or pancreatitis is suspected;
triglyceride levels.

Pleural fluid of the exudative type can be distinguished from transudative pleural fluid in the following cases:

Liquid/serum LDH ratio ≥ 0.6
Liquid/serum protein ratio ≥ 0.5
Fluid LDH level within the upper two-thirds of normal serum LDH level

There are no complications during thoracocentesis, but their development is possible after the procedure.

The main complications after the procedure of thoracocentesis and drainage:

Pneumothorax (11%)
Hemothorax (0.8%)
Rupture of the liver or spleen (0.8%)
Diaphragmatic wound
empyema
Tumor

Minor complications include the following:

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Specialty: Audiologist Experience: 7 years

Thoracocentesis: indications, preparation and conduct, consequences

Thoracocentesis (thoracentesis) is a puncture procedure chest wall to enter the pleural cavity. Thoracocentesis is performed for the purpose of diagnosis or for the purpose of treatment.

From the inside, our chest is lined with a parietal pleura, and the lungs are covered with a visceral sheet. The space between them is the pleural cavity. Normally, it always contains about 10 ml of liquid, which is constantly formed there and simultaneously absorbed. This fluid is needed for a good sliding of the pleural sheets during breathing.

The pleura is rich in blood vessels. In a number of diseases, the permeability of these vessels increases, and the production of fluid increases or its outflow is disturbed. As a result, a pleural effusion is formed: the volume of fluid increases dramatically, and it cannot be eliminated by any other means than evacuation through a puncture.

When is thoracocentesis performed?

For diagnostic purposes when the diagnosis is unclear. In these cases, a puncture is performed with any amount of exudate.
With a therapeutic purpose to reduce the symptoms of respiratory failure in exudative pleurisy any etiology.
For the same purpose, with the accumulation of non-inflammatory effusion (transudate) in the chest cavity in case of heart failure, cirrhosis of the liver, kidney failure, some other pathologies.
With the consequences of chest injuries - hemothorax, pneumothorax, hemopneumothorax.
With spontaneous pneumothorax.
For the purpose of evacuation of pus and drainage of the chest with pleural empyema.
For the purpose of administering drugs (antibiotics, antiseptics, anti-tuberculosis, anticancer drugs).

Contraindications for thoracocentesis

If a we are talking about the evacuation of a large amount of fluid or air from the chest cavity, there are no absolute contraindications to pleural puncture, since it is this case is a violation of vital important functions(any effusion or air compresses the lung and shifts the heart to the side, which can lead to acute insufficiency of these vital important organs).

Therefore, thoracocentesis in such cases cannot be performed, unless the patient himself or his relatives refused the procedure in writing.

Relative contraindications to thoracocentesis:

Reduced blood clotting (INR greater than 2 or platelet count less than 50 thousand).
portal hypertension and varicose veins pleural veins.
Patients with one lung.
Severe severe condition of the patient, hypotension.
Fuzzy localization of the effusion.
Difficult to stop cough.
Anatomical defects of the chest.

Examinations before the thoracentesis procedure

If fluid or air is suspected in the pleural cavity, the patient is usually sent for x-rays. This diagnostic method is quite informative in this case and often it is enough to clarify the presence of effusion and its quantity, as well as to diagnose pneumothorax (presence of air in the chest cavity).

For the same purpose, one can ultrasound procedure pleural cavity (ultrasonography). Ideally, thoracocentesis should be performed under direct ultrasound guidance.

Sometimes in doubtful cases appointed CT scan chest (mainly to clarify the localization of encysted pleurisy).

Preparation for the thoracocentesis procedure

Thoracocentesis can be performed on an inpatient or outpatient basis. Outpatient thoracocentesis can be performed as diagnostic procedure, and also as a method symptomatic treatment in patients with a clear diagnosis ( oncological diseases, effusions in heart failure, liver cirrhosis).

position of the patient during thoracocentesis

Consent to the procedure must be signed. If the patient is unconscious, the consent is signed by close relatives.

Before the procedure, the doctor once again determines the level of fluid by percussion or (ideally) ultrasound.

It is preferable that the procedure be performed by a thoracic surgeon using a special thoracocentesis kit. But in emergency cases Thoracocentesis can be performed by any doctor with a suitable thick needle.

Thoracocentesis is performed under local anesthesia. The position of the patient is sitting on a chair, with the body tilted forward, hands folded on the table in front of him or brought behind his head.

Particularly anxious patients can be premedicated with a tranquilizer before the procedure.

If the patient is in serious condition, the position may be horizontal. serious condition The patient also requires standard monitoring (BP, ECG, pulse oximetry), access to the central vein, and oxygenation through a nasal catheter.

How is thoracocentesis performed?

The puncture is carried out in the 6-7th intercostal space in the middle between the mid-axillary and posterior axillary lines. The needle is inserted strictly along the upper border of the rib to avoid damage to the neurovascular bundle.

The skin is treated with an antiseptic.

Perform tissue infiltration with a solution of novocaine or lidocaine, gradually moving the syringe with a needle from the skin deep into all layers. The piston in the syringe is periodically retracted in order to notice in time if the needle enters the vessel.

The periosteum of the rib and the parietal pleura should be especially well anesthetized. When the needle enters the pleural cavity, a failure is usually felt, and when the piston is pulled up, pleural fluid begins to flow into the syringe. At this point, the depth of penetration of the needle is measured. The anesthesia needle is removed.

A thick thoracocentesis needle is inserted at the site of anesthesia. It is passed through the skin subcutaneous tissue approximately to the depth that was noted during anesthesia.

An adapter is attached to the needle, which is connected to the syringe and to the tube attached to the suction. The pleural fluid is drawn into a syringe for referral to the laboratory. The liquid is distributed into three test tubes: for bacteriological, biochemical research, as well as for the study of cellular composition.

To remove large volumes of fluid, a soft, flexible catheter is inserted through a trocar. Sometimes a catheter is left to drain the pleural cavity.

Usually, no more than 1.5 liters of liquid are sucked off at a time. With the appearance of severe pain, shortness of breath, severe weakness, the procedure is stopped.

After the puncture is completed, the needle or catheter is removed, the puncture site is again treated with an antiseptic and an adhesive bandage is applied.

Video: Bulau pleural cavity drainage technique

Video: an example of a thoracocentesis

Video: performing a pleural puncture for lymphoma

Video: English educational film on pleural puncture

Thoracocentesis for pneumothorax

Pneumothorax is the entry of air into the chest cavity due to trauma or spontaneously due to rupture of the lung against the background of its disease. Thoracocentesis with pneumothorax is performed in the case of tension pneumothorax or with normal pneumothorax with an increase in respiratory failure.

The puncture of the chest wall with pneumothorax is carried out along the midclavicular line along the upper edge of the third rib. Air is aspirated with a needle or (preferably) a catheter.

The air from the pleural cavity comes out with a characteristic whistling sound. Aspirate as much air as needed to eliminate the symptoms of hypoxia.

Often, with pneumothorax, drainage of the pleural cavity is required - that is, the catheter or drainage tube is left in it for a while, the end of the catheter is lowered into a vessel with water (like a "water lock"). Removal of the drainage tube is carried out one day after the cessation of the discharge of air, after X-ray control of the expansion of the lung.

Sometimes, with chest injuries, hemopneumothorax occurs: both blood and air accumulate in the pleural cavity. In such cases, a puncture can be performed in two places: for fluid evacuation - along the posterior axillary line, for air removal - in front along the midclavicular line.

Video: thoracocentesis for decompression with tension pneumothorax

After puncture

Immediately after the puncture, a dry cough, pain in the chest (if the pleura was inflamed) may appear.

Possible complications after thoracocentesis

In some cases, thoracocentesis is fraught with the following complications:

Lung puncture.
The development of pneumothorax due to leakage of air through a puncture or from a damaged lung.
Hemorrhage into the pleural cavity due to vascular damage.
Pulmonary edema due to simultaneous evacuation of a large amount of fluid.
Infection with the development of the inflammatory process.
Damage to the liver or spleen from too low or too deep a puncture.
subcutaneous emphysema.
Fainting due to sharp decline pressure.
Extremely rare - air embolism with a fatal outcome.

Specifics of thoracocentesis

What is thoracocentesis (pleurocentesis)? This is an invasive intervention, carried out for diagnostic and therapeutic purposes.

The procedure is a puncture of the chest wall with a needle or trocar to remove fluid, air or pus that has accumulated in the pleural cavity.

In itself, the removal of exudate, transudate or air has medicinal value, and the subsequent laboratory examination of the extracted fluids is diagnostic.

Indications and contraindications for the procedure

Fluid, blood, pus, or air may accumulate in the pleural cavity various reasons. For example, due to a chest injury, as a result of an operation, etc. Air accumulation (pneumothorax) leads to an increase in pressure in the pleural cavity and, as a result, to dysfunction of the chest organs, primarily the lungs. There is a depression of the mechanism of respiration.

If, along with air, blood also accumulates in the cavity, then this phenomenon is called hemothorax. This is an even more dangerous situation, requiring an indispensable medical intervention. Drainage is necessary to normalize the pleural lumen and the condition of the chest organs. It is for this purpose that thoracocentesis is performed.

It is assigned to resolve the following problems:

pneumothorax;
hemothorax;
postoperative drainage;
post-traumatic drainage;
pleural empyema.

Pneumothorax often results from lung injury piece of rib bone. At the same time, air from the lung begins to flow into the pleural cavity and accumulate in it. Therefore, pneumothorax is often observed in people involved in a traffic accident.

This type of invasive intervention may not be performed for all patients, or may be prescribed according to the so-called limited indications. Contraindications include:

hypoxia;
acute hypoxemia;
blood clotting disorders;
heart rhythm disturbances;
violation of hemodynamics;
lesions of the skin in the area of thoracocentesis;
pyoderma;
refusal of the patient to undergo the procedure.

If the patient is on artificial ventilation lungs, thoracocentesis is prescribed with restrictions. It should be noted that the early childhood is not a contraindication to the procedure. It can be assigned to children of both the eldest and younger age. Drainage of the pleural cavity is carried out for children from 6 months.

Conduct and possible complications of the procedure

For the procedure, the patient must take sitting position, leaning forward and leaning on any support. First of all, the doctor determines the place for the introduction of the trocar. In order to reduce pain, this area of \u200b\u200bthe skin is treated with anesthetic solutions. Then a puncture is taken to determine whether there is indeed an accumulation of blood, pus, fluid, etc. in this area. If their presence is confirmed, a trocar is inserted into the pleural lumen, after which drainage occurs.

You should know: in some cases, thoracocentesis is performed with the patient lying or reclining, and the drainage tube is inserted into a previously made incision - the method of the procedure is determined by the doctor.

For drainage of the pleural cavity, rubber tubes of various lengths are used. The length of each of them corresponds to the nature of the pumped out substance. So, for example, a small tube is used to remove air, a medium tube is used to pump out liquid, and a large tube is used to drain blood and pus. Each tube has several holes at the end.

After taking a puncture, a tube is inserted into the hole, corresponding to the nature of the extracted substance. The tube is fixed with a suture to the chest wall, additionally fixed with a bandage. To ensure that air does not enter the pleural cavity through the tube, moving in the opposite direction, it is connected to a water container. Next, you need to check whether the tube was installed correctly, its position in the cavity. For this purpose, the patient is subjected to x-ray examination.

The tube must be removed only after the situation normalizes and the cause that led to the thoracocentesis is eliminated. The fact that such a state has come is indicated by a number of indicators.

With homothorax, for example, such an indicator is the volume of secretions, which has decreased to an average daily of 100 ml. The tube is removed at the moment of strong exhalation, after which the hole is closed with gauze soaked in oil. The fatty film prevents air from entering.

As a result of the procedure, there may be various complications. The reason for this may be, for example, wrong position body of the patient, incorrect introduction of the trocar, errors in the procedure, etc. In this case, the following consequences may be observed:

injury to the intercostal artery;
infection (with a partial purulent residue);
lung rupture;
puncture of the spleen or liver, damage to other abdominal organs;
hemorrhage in the abdominal, pleural cavity or in the chest wall;
pneumothorax;
pulmonary edema.

It should be noted that such Negative consequences recorded very rarely. AT exceptional cases may even follow fatal outcome as a result of an air embolism.

In order to avoid such complications, as well as to increase the effectiveness of the procedure, the patient is preliminarily assigned an X-ray examination.

As a result, the doctor can determine the size and position of the sinus filled with air or fluid. Accordingly, it becomes possible to choose the optimal depth and direction of the puncture, assess possible risks and prevent the onset of negative consequences.

It should be taken into account that complications arise after any, especially invasive, intervention, however, the need for such manipulations is higher than the risk of possible undesirable consequences.

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Thoracocentesis in cats and dogs

Thoracocentesis (thoracocentesis) is a procedure in which the pleura is punctured through the intercostal space in order to divert and aspirate pathological contents (transudate or exudate), normalize respiratory function, and for content diagnostics.

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Polyuria - increased volume of urination, in which urine has a low relative density, is almost colorless and is always accompanied by increased water intake (polydipsia). The kidneys in this process play essential role, being the regulator water-salt balance organism. Polyuria and polydipsia are indicators.

emergency medicine

Indications for thoracocentesis

An incision-puncture of the chest wall for the introduction of a drainage tube - thoracocentesis, in an outpatient setting is indicated for spontaneous and tension pneumothorax, when the puncture of the pleural cavity is insufficient to resolve threatening state. Such situations sometimes occur with penetrating wounds of the chest, severe closed injuries associated with tension pneumothorax, hemopneumothorax. Drainage of the pleural cavity is also shown with massive accumulation of exudate; in the hospital - with pleural empyema, persistent spontaneous pneumothorax, chest injuries, hemothorax, after operations on the organs of the chest cavity.

Thoracocentesis technique

Thoracocentesis and insertion of a drainage tube are most easily accomplished using a trocar. In the second intercostal space along the midclavicular line (to remove excess air) or in the eighth along the midaxillary line (to remove exudate) infiltration anesthesia 0.5% novocaine solution to the parietal pleura. A scalpel is used to make an incision-puncture of the skin and superficial fascia, slightly larger than the diameter of the trocar. A drainage tube is selected for it, which should pass freely through the trocar tube. More often, siliconized tubes from disposable blood transfusion systems are used for this purpose.

Through skin wound a trocar with a stylet is introduced into the pleural cavity along the upper edge of the rib. It is necessary to apply a certain force to the trocar, simultaneously making small rotational movements with it. Penetration into the pleural cavity is determined by the feeling of "failure" after overcoming the parietal pleura. Remove the stylet and check the position of the trocar tube. If its end is in the free pleural cavity, then air enters through it in time with breathing or pleural exudate is released. A prepared drainage tube is inserted through the trocar tube, in which several lateral holes are made (Fig. 69). The metal tube of the trocar is removed, and the drainage tube is fixed to the skin with a silk ligature, circling the thread 2 times around the tube and tightly tightening the knot to prevent drainage from falling out when the patient moves and during transportation.

Rice. 69. Thoracocentesis. Insertion of a drainage tube using a trocar. a - introduction of the trocar into the pleural cavity; b - removal of the stylet, the hole in the trocar tube is temporarily covered with a finger; c - introduction of a drainage tube into the pleural cavity, the end of which is pinched with a clamp; d, e - removal of the trocar tube.

If a trocar is not available, or if a drain larger than the trocar tube needs to be inserted, use the technique shown in Fig. 70. After the incision-puncture of the skin and fascia, the closed jaws of the Billroth clamp are inserted with some effort into the soft tissues of the intercostal space (along the upper edge of the rib), pushing the soft tissues, the parietal pleura apart and penetrating into the pleural cavity. The clamp is turned up, parallel inner surface chest wall and move apart the branches, expanding the wound of the chest wall. The drainage tube is seized with the removed clamp and together they are introduced into the pleural cavity along the previously prepared wound channel. The clamp with divorced branches is removed from the pleural cavity, at the same time holding and pushing deep into the drainage tube so that it does not move along with the clamp. Check the position of the tube by sucking air or pleural fluid through it with a syringe. If necessary, advance it deeper and then fix it with a silk ligature to the skin.

Figure 70 Insertion of a pleural drain with a clamp. a - incision-puncture of the skin and subcutaneous fat; b - blunt expansion of the soft tissues of the intercostal space with a Billroth clamp; in - the imposition of a clamp on the end of the drainage tube; d - introduction of drainage into the pleural cavity through the prepared wound channel; e - fixing the drainage tube to the skin with a ligature.

A finger is put on the free end of the drainage tube and fixed with a circular ligature. rubber glove with a dissected top and placed in a jar with antiseptic solution(furatsilin), covering only the end of the tube. This simple device prevents the suction of air from the atmosphere into the pleural cavity during inspiration. A kind of valve system is created, allowing fluid and air to only exit the pleural cavity to the outside, but preventing it from flowing out of the jar. When transporting a patient, the end of the drainage is placed in a bottle, which is tied to a stretcher or to the belt of the patient, who is in a vertical (sitting) position during transportation. Even if the tube (with a dissected finger from the glove at the end) falls out of the vial, the valve mechanism of drainage will continue to operate: if negative pressure occurs in the pleural cavity, the walls of the finger from the glove collapse and air access to the peripheral end of the drainage is blocked. AT specialized hospitals the drainage tube is connected to a suction (active suction system), which allows you to keep the lung in a straightened state.

Minor surgery. IN AND. Maslov, 1988.

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Thoracocentesis: indications, technique;

Indications. Pleural effusion of unclear etiology, detected radiographically, is the most common indication for pleural puncture; it is especially necessary if an exudative effusion is suspected. Patients with transudates usually do not undergo thoracocentesis, except in cases of suspicious effusion, when it is necessary to make sure that there are no reasons for its appearance other than an increase in hydrostatic pressure or a decrease in oncotic pressure. Thoracocentesis is indicated for infections of unknown nature or ineffectiveness of antimicrobial therapy. It is rarely needed for simple parapneumonic effusions if the patient is improving. Analysis of the pleural effusion is important for diagnosing and staging suspected or known malignancy, and for unusual causes of fluid in the pleural cavity (eg, hemothorax, chylothorax, or empyema), since these cases usually require additional invasive treatment. Sometimes it is necessary to investigate the effusion that occurs with systemic diseases (for example, with collagenoses).

Therapeutic indications. Thoracocentesis is used to eliminate respiratory failure caused by a massive pleural effusion, as well as to introduce antitumor or sclerosing agents into the pleural cavity (after removal of the effusion). Most doctors prefer to use thoracostomy tubes in the latter case.

Technique. Thoracocentesis can be performed in different areas of the chest, depending on the indication (see terms Drainage of the pleural cavity, “Thoracotomy”). If it is necessary to perform thoracocentesis of the lateral wall of the chest, the patient is placed on the healthy half, under which a roller is placed so that the intercostal spaces move apart, if in the II-III intercostal space in front - on the back. When diagnosing respiratory failure, thoracocentesis should be performed with the patient half-sitting.

After processing the surgical field (within a radius of at least 10 cm) with a 0.25-0.5% solution of novocaine, local anesthesia of the skin is performed along the projection of the intercostal space, and with a longer needle - anesthesia of the subcutaneous tissue and muscles. The advancement of the needle further should be accompanied by the continuous injection of novocaine solution. When the pleura is pierced, pain will appear. To clarify the location of the needle in the pleural cavity, pull the syringe plunger towards you - the entry of air or other contents into the syringe indicates that the needle has entered the pleural cavity. After that, the needle is slightly removed from the pleural cavity (for anesthesia of the parietal pleura) and 20-40 ml of novocaine solution is injected. Then the needle connected to the syringe is slowly and perpendicular to the chest cavity advanced into the pleural cavity, continuously bringing the syringe plunger towards itself.

The flow of fluid or air from the pleural cavity into the syringe makes it possible to characterize the depth of the free pleural cavity, to which it is safe to insert a trocar or clamp without fear of touching the internal organs. Having calculated the depth of the free pleural cavity by this method, the SKIN is cut and the soft tissues are moved apart and a trocar or clamp is inserted into the pleural cavity, depending on the purpose of the thoracocentesis. If, after this manipulation, drainage is introduced into the pleural cavity, the latter is fixed with a U-shaped suture, the ends of the thread are tied with a bow. This is done so that after removal of the drainage, it is possible to tighten the knot and close the wound without violating the tightness of the pleural cavity. If drainage is not introduced, the wound is sutured with 1-2 sutures, after which an aseptic dressing is applied.

What is thoracocentesis (pleurocentesis)? This is an invasive intervention, carried out for diagnostic and therapeutic purposes.

The procedure is a puncture of the chest wall with a needle or trocar to remove fluid, air or pus that has accumulated in the pleural cavity.

In itself, the removal of exudate, transudate or air is of therapeutic value, and the subsequent laboratory examination of the extracted fluids is diagnostic.

Indications and contraindications for the procedure

Fluid, blood, pus or air can accumulate in the pleural cavity for various reasons. For example, due to a chest injury, as a result of an operation, etc. The accumulation of air (pneumothorax) leads to an increase in pressure in the pleural cavity and, as a result, to a violation, primarily of the lungs. There is a depression of the mechanism of respiration.

If, along with air, blood also accumulates in the cavity, then this phenomenon is called hemothorax. This is an even more dangerous situation, requiring indispensable medical intervention. Drainage is necessary to normalize the pleural lumen and the condition of the chest organs. It is for this purpose that thoracocentesis is performed.

It is assigned to resolve the following problems:

pneumothorax;
postoperative drainage;
post-traumatic drainage;
pleural empyema.

Pneumothorax often results from damage to the lung by a piece of costal bone. At the same time, air from the lung begins to flow into the pleural cavity and accumulate in it. Therefore, pneumothorax is often observed in people involved in a traffic accident.

This type of invasive intervention may not be performed for all patients, or may be prescribed according to the so-called limited indications. Contraindications include:

If the patient is on artificial lung ventilation, thoracocentesis is prescribed with restrictions. It should be noted separately that early childhood is not a contraindication to the procedure. It can be assigned to both older and younger children. Drainage of the pleural cavity is carried out for children from 6 months.

Conduct and possible complications of the procedure

For the procedure, the patient must take a sitting position, leaning forward and leaning on any support. First of all, the doctor determines the place for the introduction of the trocar. In order to reduce pain, this area of \u200b\u200bthe skin is treated with anesthetic solutions. Then a puncture is taken to determine whether there is indeed an accumulation of blood, pus, fluid, etc. in this area. If their presence is confirmed, a trocar is inserted into the pleural lumen, after which drainage occurs.

You should know: in some cases, thoracocentesis is performed with the patient lying or reclining, and the drainage tube is inserted into a previously made incision - the method of the procedure is determined by the doctor.

The tube must be removed only after the situation normalizes and the cause that led to the thoracocentesis is eliminated. The fact that such a state has come is indicated by a number of indicators.

Various complications may occur as a result of the procedure. The reason for this may be, for example, an incorrect position of the patient's body, incorrect insertion of the trocar, errors in the procedure, etc. In this case, the following consequences may be observed:

injury to the intercostal artery;
infection (with a partial purulent residue);
puncture of the spleen or liver, damage to other abdominal organs;
hemorrhage in the abdominal, pleural cavity or in the chest wall;
pneumothorax;
pulmonary edema.

It should be noted that such negative consequences are recorded extremely rarely. In exceptional cases, even a fatal outcome as a result of an air embolism can follow.

In order to avoid such complications, as well as to increase the effectiveness of the procedure, the patient is preliminarily assigned an X-ray examination.

Sometimes, in order to diagnose the disease, the doctor needs to get the fluid that has accumulated in the pleural cavity. For this, thoracocentesis (thoracentesis) is used. In this article, we will explain what is this procedure and how it is carried out.

Thoracocentesis is invasive manipulation during which a needle or trocar is pierced through the chest wall to remove fluid or pus that has accumulated in the pleura.

A similar procedure is carried out in the operating room or in the patient's room. If required, the fluid obtained during the manipulation is sent to the laboratory for examination.

Thoracocentesis is used for therapeutic purposes - to remove liquid, and as a diagnostic to find out the factors that provoked the accumulation of fluid in the chest cavity.

Indications for carrying out

This procedure is carried out in such cases:

Limitations for thoracocentase

When it is necessary to evacuate a large volume of fluid or air from a cavity in the sternum, then there are no unconditional contraindications to thoracentesis. Indeed, in this situation, it is understood that the work of vital organs has been disrupted (the accumulation of fluid or air compresses the lungs and moves the heart to the side, this sometimes causes the formation of acute insufficiency in these bodies).

For this reason, the procedure is not carried out in this case, only when the patient himself or one of his relatives signed a refusal from thoracocentesis.

Comparative limitations to thoracocentesis are as follows:

Reduced blood clotting (INR more than 2 or platelets less than 50 thousand).
With portal hypertension and varicose veins in the pleural veins.
If the patient has one lung.
With severe severity of the human condition, hypotension.
When it is inaccurately determined where the effusion is localized.
With difficult to stop cough.
With anatomical defects of the sternum.

How to prepare

Pleurocentesis is performed in a hospital or outpatient setting. Outpatient thoracocentesis is used for diagnostic purposes, as well as symptomatic therapy in patients with an established diagnosis (in the presence of oncological pathology, effusions in heart failure, liver cirrhosis).

AT without fail the patient must sign a consent to the invasive intervention. When the patient is unconscious, the consent is signed by the next of kin.

Important. Before starting thoracocentesis, the doctor re-determines the volume of the effusion by using percussion or ultrasound diagnostics.

As a rule, such an operation is performed by a thoracic surgeon with special instruments for thoracentesis. However, in emergency it is possible to perform thoracentesis by any doctor using an appropriate thick needle.

The procedure is carried out under local anesthesia. During thoracocentesis, the patient sits on a chair, tilting his torso forward, folds his hands on a table that stands in front of him or turns his head.

If the patient is in anxiety, then a tranquilizer may be administered to him.

For severely ill patients, pleurocentesis is performed horizontally. In this case, the patient is also subjected to standard monitoring (pressure, ECG, pulse), access to central vein and oxygenation with a nasal catheter.

Technique for performing thoracocentesis

A puncture is made in the region of 6-7 intercostal space between the middle axillary and posterior axillary lines. The needle is inserted exactly along the upper border of the rib to prevent disturbances in the bundle of nerve vessels.

Important. The skin is treated with an antiseptic.

The integument is impregnated with novocaine or lidocaine by methodically advancing the syringe with a needle from skin inside through all the covers. The piston in the syringe is retracted from time to time, this is necessary for timely detection that the needle has entered the vessel.

Carefully anesthetize the costal periosteum and parietal membrane. When the needle enters the chest cavity, it can be felt that it has failed, and during the piston tightening, serous contents are noticed entering the syringe. At this point, measure how deep the needle has penetrated. The anesthesia needle is removed.

A thick needle for thoracentesis is inserted into the place where anesthesia was performed. It is carried out through the skin and subcutaneous membranes approximately at the distance that was noted during anesthesia.

An adapter is connected to the needle, combined with a syringe and a tube attached to the suction. serous fluid is drawn into a syringe to be sent to a laboratory later. The liquid is distributed in three test tubes: for bacteriological and biochemical examination, as well as for determining the cellular structure.

The adapter then switches to suction to evacuate the effusion.

To remove a large amount of effusion, a soft flexible catheter is used, which is inserted using a trocar. In some cases, a catheter may be left in place to drain pleural fluid.

As a rule, no more than one and a half liters of effusion is sucked out instantly. If appears strong pain, shortness of breath or severe weakness, the procedure is terminated.

At the end of the procedure, the needle or catheter is removed, and the area where the puncture was made is treated again. antiseptic and apply an adhesive bandage.

After thoracentesis, some complications may occur. Sometimes infection can begin if the pus is not completely removed or it has accumulated again.

It should be noted that there is a possibility of complications with any, especially invasive, intervention, but the need for such a procedure more danger possible undesirable consequences.

Conclusion

If there is a need to evacuate fluid from the pleural cavity in diagnostic or medicinal purposes then a thoracocentesis is performed. Although absolute contraindications and are absent, however, there are some restrictions on such an invasive intervention, so it is necessary to consult a doctor.

Thoracostomy (in other words, fenestration of the chest wall) is performed to fast withdrawal intoxication by simultaneous emptying of the abscess formed during pyopneumothorax, and creating access for its sanitation through a wide thoracotomy wound. Thoracocentesis- puncture of the chest wall in order to establish a diagnosis, to obtain the contents of the chest cavity, as well as to remove accumulated exudate or transudate for the purpose of treatment.

Thoracocentesis

Indications:

Establishment of the etiology of pleural effusion;
Removal of pleural effusion for therapeutic purposes;
For the administration of drugs;
Emergency removal of air in tension pneumothorax.

Contraindications:

Obliteration of the pleural cavity;
Coagulopathy - INR more than 2, thrombocytopenia less than 50×109/l;
Varicose pleural veins in portal hypertension.

Thoracocentesis technique

A chest x-ray should be taken prior to the procedure. In case of pneumothorax, to remove air from the pleural cavity, the puncture should be carried out in the 2nd intercostal space along the midclavicular line (with the patient sitting) or in the 5th-6th intercostal space along the midaxillary line (with the patient lying on a healthy side with a hand abducted behind the head).

Attention. For pneumothorax, perform pleural puncture only in the most urgent cases (for example, tension pneumothorax). In the vast majority of cases, pneumothorax requires pleural catheterization.

With hydro- and puncture can be performed in the 6-7 intercostal space along the posterior axillary or scapular line (landmark - the lower edge of the scapula). A puncture is done to the patient in a sitting position - a person sits on the edge of the bed, putting his hands behind his head or putting them on the bedside table. The nurse insures him by holding his shoulders. If the patient cannot be seated, then the puncture site is chosen closer to the midaxillary line in the 5th-6th intercostal space.

1. Treat the puncture site with an antiseptic solution;

2. Draw 10 ml of 1% lidocaine solution into the syringe. At the point chosen for puncture intramuscular needle(G22) Perform layer-by-layer anesthesia of the skin, subcutaneous tissue, muscles, rib periosteum, and parietal pleura. Gently advance the needle directly over top edge the underlying rib into the pleural cavity, the syringe is in the “piston towards itself” position. After the appearance of pleural contents in the syringe, remove the needle;

3. Take a needle from the pleural puncture kit or another of suitable gauge (G14-18) and length (8-10 cm) and connect it to a 10 ml syringe;

4. At the selected point, maintaining the vacuum in the syringe (the “piston towards you” position), slowly and smoothly pierce the chest wall and parietal pleura. The puncture of the chest wall is done, focusing on the upper edge of the underlying rib in order to avoid injury to the intercostal vessels;

5. If air or pleural contents begin to enter the syringe, the advance of the needle is immediately stopped;

6. Collect pleural contents into the syringe for laboratory research. With hemothorax, a Revelua-Gregoire test is performed - if the blood obtained from the pleural cavity forms clots, this indicates continued bleeding from the pleural cavity;

7. Depending on the situation, a conductor is passed through the needle and the pleural cavity is catheterized according to Seldinger (preferred option). Or attach a disposable blood transfusion system to the needle. Connect the distal end of the system to the suction low pressure(vacuum 20-30 cm water column), or if the contents of the pleural cavity is fluid, simply lower its end below the level of the puncture.

Use a special catheter for pleural catheterizations. If the catheter you need is not available and you are using a central vein catheter to catheterize the pleural cavity. Choose for these purposes a catheter of the maximum diameter available to you. Make a small (1/3 of the catheter diameter) lateral hole 3-4 cm from the distal end with a scalpel blade - this will dramatically increase the efficiency of its work. Do not use peripheral devices for drainage of the pleural cavity. venous catheters They are too thin and bend easily.

8. The signal to remove the needle (or catheter) is the appearance of pain as a result of its contact with visceral pleura, cessation of the release of fluid, air;

9. If the fluid is poorly evacuated, by changing the position of the patient's body, achieve an increase in the outflow rate. Or connect a low-pressure suction to the catheter for several hours via an extension cord. It is clear that when a needle was used instead of a catheter in a patient, such manipulations cannot be carried out;

10. After the end of the procedure, the skin puncture site is treated with an antiseptic solution and covered with a sterile gauze sticker.

11. Take a follow-up chest x-ray.

Thoracostomy

Indications

Pleural effusion in a significant amount, which could not be evacuated by pleural puncture;
Purulent pleurisy.

Execution Method

Training

1. Specify the localization of pneumothorax or pleural effusion using chest x-ray;

2. The patient should be in a prone or reclining position, the arm on the side of the lesion is thrown behind the head. The triangle is highlighted in the figure, where the introduction of drainage is most safe (6-4 intercostal space along the anterior axillary or mid axillary line);

3. Provide venous access and oxygenation through a nasal catheter. Consider the advisability of premedication (, narcotic analgesics);

4. Set up standard monitoring: ECG, SpO2, non-invasive blood pressure;

5. Determine the fifth intercostal space along the midaxillary line (located at the level of the nipple in men and the base of the mammary gland in women). With a marker, or otherwise, mark this point;

6. Widely treat the puncture site with an antiseptic and limit the skin with sterile wipes;

7. Draw 20 ml of 1% lidocaine solution into the syringe. At the point chosen for puncture with an intramuscular needle, perform layer-by-layer anesthesia of the skin, subcutaneous tissue, muscles and parietal pleura, focusing on the upper edge of the underlying rib;

8. Use a scalpel to make a 1-1.5 cm incision in the intercostal space just above the upper edge of the underlying rib. Drainage is prepared in advance. The end of the drainage, intended for insertion into the pleural cavity, is cut obliquely. Stepping back 2-3 cm from it, 2-3 side holes are made. 8-12 cm above the upper lateral opening, which depends on the thickness of the chest and is determined by pleural puncture, a ligature is tightly tied around the drainage. The other end of the drain is clamped with a clamp.

9. Further introduction of the drainage tube into the pleural cavity can be carried out through a trocar or in an open way using a clamp. And if smaller diameter drainages are used - according to Seldinger.

A trocar with an inserted stylet is inserted into the pleural cavity through the incision with rotational movements, focusing on the appearance of a feeling of failure. Then the stylet is removed and a drainage tube is inserted through the trocar sleeve into the pleural cavity. After removing the sleeve, the tube is carefully pulled out of the pleural cavity until a control ligature appears.

Open method: through the incision of the skin and subcutaneous tissue, a drainage tube is inserted into the pleural cavity with rotational movements, clamped with the tip of a clamp with sharp branches. After feeling a sense of failure, the clamp is slightly opened, and the drain is pushed to the required depth with the other hand. Then the clamp is carefully removed, holding the tube at the required level.

A U-shaped suture is placed around the tube to seal the pleural cavity. The seam is tied with a bow on the balls. The tube is fixed to the skin with 1-2 sutures, paying attention to the tightness of the sutures around the tube. Seldinger catheterization uses special kits and catheters for drainage of the pleural cavity.

Attention. Do not use disposable tubes as drains. intravenous systems. They are thin-walled, easily pinched.

10. In the case of a small pneumothorax, or in the presence of a liquid effusion, a 10-12 size French catheter (1Fr = 0.33 mm) is quite sufficient. With hemothorax - the size of the drainage tube should be at least 24 Fr (preferably 28-30 Fr). Thoracostomy using a trocar catheter, or a Seldinger catheter, is quite effective in pneumothorax, pleurisy, but not in the case of hemothorax. In case of hemothorax, immediately install a large diameter drainage tube (28-30 Fr).

11. Place a gauze bandage between the skin and the drainage tube and secure the drainage tube to the chest with adhesive tape.

12. Through an extension cord, connect the drain tube to a special (cavitary) low pressure suction. Vacuum - 20 cm of water. Art. (not higher - 30 cm water column).

Attention. Never connect the drain to a conventional surgical suction. This is deadly for the patient.

Another option is Bulau drainage. A safety valve is fixed at the outer end of the drainage tube - a finger from a rubber glove with a 1.5-2 cm long cut. Or an industrial valve. The valve must be immersed to a depth of 3-4 cm in a vial with a sterile solution (sodium chloride 0.9%). The tube is fixed so that the valve does not float and is always in solution. The valve prevents air and the contents of the jar from entering the drain tube. Do not pinch pleural drainage even on short period up to the moment of its removal, if the patient is undergoing mechanical ventilation.

13. Once the drain is in place, take a follow-up chest x-ray.

Removal of pleural drainage

With pneumothorax, the drainage is removed if air has not been discharged through the tube during the day. In other cases, the question of the time of removal of the tube is decided individually. Usually, the drainage is removed when the volume of discharge from the pleural cavity becomes less than 100-200 ml / day.

Deletion sequence

1. Remove the bandage and adhesive tape, cut off the seam that secures the tube;

2. Apply pressure to the skin next to the tube and remove the drain while exhaling;

3. Tie a U-shaped seam, apply a gauze bandage;

4. Take a follow-up chest x-ray to rule out pneumothorax.