Thoracentesis

CHAPTER 1

Hey, everyone. My name's Alex Lopez. I am a fifth year pulmonary critical care fellow, here at Penn State Hershey. What I'm gonna tell you all about today is a thoracentesis that we're about to do bedside. So this patient, she is a 54-year-old female. She's been having a recurrent left-sided effusion. And so in order you send that fluid off for testing, we're gonna perform a thoracentesis today. So in general, this is a bedside procedure that we do pretty regularly in pulmonology. Like I said, we do it at the bedside. There's a couple different positions the patient can be in. They can be sitting on the edge of the bed with their head forward, leaning on pillows, or if they're not able to do that, they can also be laying down in the lateral decubitus position. We ultrasound the area, so we know exactly how much fluid we have, and where we're going. We sterilize the area very well before we proceed with any procedure. I'm wearing sterile gloves. There's a sterile drape. The main thing is lidocaine. That's the most painful part of the procedure for the patient. We numb up the skin area very well, and then numb up the track until we reach the pleural space. Once we have done that, we have a catheter. It's a Safe-T-Centesis catheter with a blunt end. So when you're going into that pleural space, if you do hit any lung, it shouldn't puncture the lung. So before you insert the catheter, after you've numbed up the area, you wanna make a very small skin nick. There's a scalpel in your tray that you'll see here in a little bit, during the video. You make a very small skin nick. You insert the catheter into that space, and you withdraw your needle. Once you're in the space, you draw out the fluid, only about 50 milliliters at a time. The lung doesn't like to get much more than that. That negative pressure can be very painful for the patient. Once your catheter is in place, there's a two liter bag that comes in the kit. The connector to the bag, the long end goes towards the bag. The short end goes to the patient, and you withdraw the fluid through that because it's a one way valve. So you can withdraw the fluid out and it goes directly into the bag, not back into the patient. 'cause you wouldn't wanna introduce air into that pleural space. Once you've drained all the fluid, generally no more than two liters at a time, any more than that it can be very painful for the patient. You can also get something called re-expansion, pulmonary edema. So that's the fluid shift, and it causes fluid to go into the lungs themselves. So we don't generally take off more than two liters at a time. Once the catheter's moved to the space, as you're pulling the catheter out, you should ask the patient to hum. That creates some negative pressure as you're pulling that catheter out to prevent air from getting trapped in the subcutaneous space. And that can cause subcutaneous emphysema. That can be uncomfortable for the patient afterwards as well. You put a bandage over the area. Generally we recommend keeping that on for at least 24 hours after the procedure. Patients can shower and bathe as they please. After a thoracentesis, it's recommended you get a chest x-ray to look for one to make sure the fluid that you just drained is gone, and look for any residual fluid. And also to look for a pneumothorax, which is one of the known complications of a thoracentesis. Generally it happens about 1 to 2% of the time. So a very rare complication, but does happen. So you wanna get a chest x-ray afterwards. All the fluid gets sent off for testing. So we test for cell counts, we culture the fluid to look for bacterias, funguses, anything like that. And then we also send it off for cytology to look for cancer cells. Because there's a lot of different reason this fluid could be there. And so one of the reasons we drain it often is to send it for testing and figure out why it's there.

CHAPTER 2

Just identifying the best spot here. So that looks pretty good. So we have a good distance here. We have the diaphragm right here, coming in and out is collapsed lung right there. And this is all your pleural fluid right here. So that's about four centimeters of fluid or so. So that's a pretty good spot. Okay. So I like that there. Then you wanna mark your spot, so you're just gonna feel a marker on your back here. Okay? Okay. Just gonna reconfirm you like that spot. We got a fluid back there, okay? Okay.

CHAPTER 3

So our kit here. This is a sterile kit behind you. So, I'm just opening this up on the side of the bed here. I'm just putting on my gloves and then I'll talk you through everything I'm doing. Okay? Okay. So this is our bag that we'll eventually put our fluid into. Are there no ChloraPreps? Oh, there's one. Okay. All right. I'm gonna start with cleaning up the area here. And so this is a a sterile procedure, and that everything on the skin is sterile. I'm wearing sterile gloves. And we'll put a sterile drape on here soon. Okay. You wanna give yourself a much bigger area than you think you'll use. And so this is our drape here. It's got a big sticky. So this is the spot that we'll put over and then it has a sticky at the top to keep it from slipping. Okay. And then just to give yourself some more working room here, I tend to put this at the bottom as well. And I'll use these little stickies just to keep it together here. Okay. Have some more sterile working place here.

CHAPTER 4

Alright so, going through your kit here, you're gonna have a lot of different things. First thing I always start with is getting your lidocaine. So, generally come with about 10 cc with lidocaine. And these are glass bottles that you'll have to break. So there's a special needle in the kit that has a filter in it and keeps any glass pieces from getting in there. So you wanna take your - prevent any injury. Open it up like that. And draw back your lidocaine. Okay. One more bottle here. All right, so that's your numbing medicine. I wanna get all the air bubbles out. And I always like to start with the tiniest needle to numb up the skin. Make it as comfortable as you can. All right, so I will - I'm gonna numb her up and then I'll set up the rest of the kit here. All right, pinch and a burn, okay? Yep. So usually start - get a little skin. Pinch! Ouch. Yeah, there's the pinch there and a little bit of burn. Okay. I know. Usually create a big wheel right underneath the skin. And anytime you're going somewhere new, you wanna pull back, make sure you're not hitting any blood vessels. Okay. All right. I'm pretty generous on the skin. I'm sorry. I know that's that medicine. It burns, but once it starts kicking in, you shouldn't feel anymore. Okay? And so when you're going in, generally you wanna feel the rib above, the rib below. And you wanna try to go just above the rib below because the neurovascular bundle lies just inferior to the rib. And so you kind of wanna avoid that and avoid the arteries there. All right. You might feel some more pinching and burning. Okay? As you're going in, always pulling back as you're advancing. Okay, feeling in some rib there. All right, just a minute. Hitting rib. Okay. Okay.

CHAPTER 5

And so this here, this is your introducer needle, catheter. So you take this - this is the catheter that will stay in the patient once you get into the pleural space, and you just insert it through there and you wanna make sure that's flush up against there. So it kind of locks in right there.

CHAPTER 6

All right? You wanna make a little bit of a skin nick here, not too big. You just wanna make it easier to advance that catheter in. Usually do kind of parallel to how the ribs are kind of shaped. Okay, that should be good there.

CHAPTER 7

Ow. Okay. More lidocaine there. Ow. Okay? Okay, we're in the space. Ow. Okay? So once you're in the space, you advance just a little further and then I drop this hand here and hold this hand steady, not inserting the needle any further and just advancing the catheter over that there. And that's it, and you're in the space.

CHAPTER 8

All right. And so the way this hooks up here, so it has a one-way valve. So as you pull fluid out and you can push it into the bag, but it won't get pushed back into the patient. 'cause you don't wanna inject any air to that space. The short side goes towards the patient. And the long side goes to the bag. And then your 60-cc syringe hooks up at the other end here. And you have your stop cock. So you wanna, it tells you which direction's off. So to open up the flow, you want it pointed this way. Alright. And now we start draining the fluid. Are there any other 60-cc syringes? Do you want me to like push this one into the bag and then, or go ahead and dump it in there? All right. So these are our samples we're sending off here. All right, how you doing? Alright. Okay. So now this is just the drainage of the fluid. I can only drain about 50 milliliters at a time, any more, the lung would get unhappy. You want this one here? All right. Oh. Should be good. Yep. Okay, all right, and now we just drain the fluid. So as I'm draining the fluid, I know this is not your first one you've had done. Coughing is very normal as that lung re-expands 'cause parts of it are collapsed right now. From that fluid as it re-expand expands, it's going to, you're gonna wanna feel like you have to cough, okay? And that's totally normal and it won't mess up anything I'm doing back here. All I have in there is a plastic catheter right now, so it can't cause any damage or anything. So if you need to sit up, move around, you can. So you said they took off two liters last week? Two liters. Okay. I think it might have been just shy of that, but yeah. Okay. Close enough. Yeah. Yeah. This is the tedious part. CT scan after? Okay. Yeah. If you start having any pain like you were telling me you had before, I want you to tell me right away. Okay? Because that could be, that's your lung telling us it might have had all it can can handle in terms of drainage and I don't want you to be uncomfortable. (patient coughing) You okay? I'll pull it out slowly. We can stop at any point, okay? Can you take like a pause? We can. Yep. We can. Yep. Is it hurting? Or is it just that cough? Yeah. I'll do it very slowly. Coughing's normal. Did the cough linger after your last one? Yeah. I spent about two, three hours doing nothing but coughing. Oh. We already got probably close to a liter. Maybe halfway, maybe. I dunno. It's hard to tell when it's laying flat like that, Huh? Too hard to tell when it's laying flat like that. How much we got. Yeah. It's almost a liter. Yeah. Now I know I'm not gonna cough myself into this. We don't want that to happen. We took out I think around almost a liter. Yep. Is that what it looked like before? Yep. Yeah. Actually it looked a little lighter. Yeah, in the tubing itself it's light. That color? Yeah. There's like two drops of blood in there and that makes all the fluid look a lot bloodier than it actually is. The fluid coming out through here is pretty light. You think this time it's lighter or previous time is lighter? Other time. Okay, take your time. Last time it looked a little lighter than what's in that jar there. This time it's dark. And that can happen, because last, whenever you injured, in the procedure, it causes a little bit of bleeding. Yeah. Here, I'm gonna take a rest for a second. Okay? Do you wanna peek? Just having a peek. It's just a little peek at the fluid. There's still lots of fluid. Yeah. You got some more fluid. You can cough, and we can let you rest. Don't hold it. If you want to cough, cough it up. Got some fluid left, but we can also stop it if you can't tolerate it. We have that plus a hundred. 1200, so 1300. Is it hurting? It hurts a little when I... Take a deep breath in? When it makes me pull air in and then it hurts. Another thing that we can do is... What you do is you unhook the 50-cc syringe, if there is a positive pressure in the pool of fluid, the fluid - you see? So, which means that it is already done. So now what another thing you can do is you can kind of put it in the level and if there is a positive then you're gonna see a lot of dripping. Oh. So then you can still drain. Oh, cool, yeah. That you can do, either way, that's what I do. I didn't know that. You still have some room to drain. Do you want me to drain more or are you done? Drain. Okay. Whenever you took it off, the fluid goes back that to that. Okay. Meeting some resistance there. I think we might be close to done here. Yeah, I mean it's not - you can pull it out. Yeah, I mean I think that's, okay. I think we're done actually. I think we've gotten all the fluid we can get. Okay? Sounds good.

CHAPTER 9

So as I pull this catheter out, I want you to kind of hum for me. Okay? Kind of create some negative pressure as I'm pulling this tube out. Okay? All right. On 3, 1, 2, 3 - hmm. Good. All right. It's out. Oh, you can stop sweetie. Unless that feels good, then you can keep humming all you want. All right. The drain is out. I don't have any fluid here. Okay. And once it's done, see here it's just a very tiny skin nick and we'll just put a Band-Aid over that and then you're done. All right, I'm gonna pull this drape off here. Okay. This is like a big bandaid coming off. All right. So I should mention about this needle, it's just, we call it the Safe-T-Centesis becaue at the tip... See at the tip, if you focus on the tip, and then you see the needle tip, and there's a safety tip, so I can touch it, it won't hurt my fingers. And then when I press it, there is kind of a one-way move created. But that's why if this is good for the kind of thoracentesis to reduce the risk of a pneumothorax. All right. And then after you're done, all she has is a bandage on there. And clean up your sharps, and that's it.

CHAPTER 10

This is how we gonna check the lung's fully expanded after what's left. So, that's liver there. So that you see that over there. There is a line here, right? So this is your diaphragm here and that's liver there. Do you want me to go up here? Let's see. And that, so this is normal lung here and I'm not seeing any... Okay, so right there there's a good, good picture, right? You see the curtain? Yeah. So this curtain sign, so this is lung here you'll see the diaphragm pop in here. And this is liver. As you breathe in, the lung - can you take a deep breath in for me? The lung comes across the liver. That's called a curtain sign. So that tells the lung is nice and open. It's moving as she breathes in. And most of the fluid's gone.