The Insertion Site for a Thoracentesis Should not be Close to the Spine

by Joseph Esherick, M.D., FAAFP, FHM

Recent studies have determined the best technique for improving the safety of thoracentesis. The patient should be sitting as upright as possible. Then, ultrasound the posterior back and locate a catheter insertion point at least 6 cm lateral to the spine and above the diaphragm. This new guideline to avoid an insertion site too medial is due to greater exposure of the intercostal vessels in this area.  The greater exposure of vessels increases the risk of bleeding complications from an ultrasound-guided thoracentesis when the insertion site is within 6 cm of the spine.  In addition, the patient should stay in the same position while their back is prepped and draped. Next, insert the catheter perpendicular to the back and immediately above the rib. Once the catheter is inserted, slow aspiration of the pleural fluid is required. Aspiration should be stopped if the patient experiences severe chest pain, severe dyspnea, subjective sensation of negative pleural pressure during aspiration, or aspiration of air.

Following these procedural techniques will help reduce complications and improve safety during thoracentesis.

 

Shojaee S, et al. Ultrasound-guided pleural access. Semin Respir Crit Care Med. 2014 Dec; 35 (6): 693-705.

Puchalski J. Thoracentesis and the risks for bleeding: a new era. Curr Opin Pulm Med. 2014 Jul; 20 (4): 377-84.

Daniels CE, et al. Improving the safety of thoracentesis. Curr Opin Pulm Med. 2011; 17 (4): 232-6.