Ultrasound Guided Thoracentesis

Ultrasound Guided Thoracentesis

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This high quality video demonstrates ultrasound guided thoracentesis on a live patient. One of the most commonly performed hospital based procedures, thoracentesis is shown step by step after using the ultrasound to locate the pleural effusion.  Clinical pearls and common pitfalls associated with ultrasound guided thoracentesis are discussed in detail.  Pleural fluid analysis is also discussed.  The video is not downloadable but may be accessed indefinitely by internet from any computer, smart phone, or tablet.  Click below to preview the Thoracentesis video.

 

A phased-ray probe is used to scan the right hemi-thorax with the probe marker directly cephalad. The probe scans the entire hemi-thorax down to the level of the diaphragm.

The ultrasound monitor reveals the echogenic rim of the diaphragm on the right side of the screen. A small wedge of atelectatic lung in the lower left and the anechoic collection of pleural fluid above.

A mark is made on the skin for the insertion site of the Thoracentesis needle with the tip of a pen which will persist even after a sterile prep. The initials of the operator are placed on the side of the Thoracentesis which is required for all chest procedures.

The right hemi-thorax is now being prepped with chlorohexidine swabs, either one 10.5 milliliter swab, or three 3.5 milliliter swabs. A sterile drape is then placed on the right hemi-thorax. The patient is placed in a sitting position with the arms resting on a table and the back as upright as possible. A Safe-T-Centesis tray is being used, the needle is placed all the way through the Thoracentesis catheter until it is fully straight. The Safe-T-Centesis catheter has a retractable blunt tip as is shown here when the blunt tip is retracted a red indicator is seen and when the blunt tip has sprung forward, the indicator becomes white.

Now local anesthesia is drawn up into a 10 mL syringe and is used to anesthetize the skin as well as the underlying soft tissue and the pleura, which are the areas with the highest density of pain fibers.

A longer needle is then used for anesthesia of the deeper soft tissues as well as the pleura. Negative aspiration is applied as the needle is slowly advanced, until you have return of pleural fluid as is seen here. Then the needle is retracted until you have no more return of pleural fluid and then the lidocaine is fully injected to numb up the pleura. After the pleura is anesthetized the needle is removed.

A scalpel is then used to nick the skin to allow insertion of the Thoracentesis catheter. The catheter is now being advanced. It is pushed with the right hand to allow the needle to advance through the soft tissue, the red indicator demonstrates that the needle is advancing first. Once the needle punctures into the pleura space there is a loss of resistance and then you'll see return of fluid as is seen there, and the catheter indicator will turn white.

At this point because the blunt tip is advancing first the full needle and catheter will be advanced one centimeter further, and then the needle is held firm and the catheter is advanced forward until the last black line is at the skin. At this point, the needle will be retracted and the catheter will be left in place.
Now, we will attach a 60 milliliter Luer-Lok syringe to the end of the drainage tube on the catheter to collect pleural fluid for diagnostic studies. The fluid stopcock is opened to the catheter to allow aspiration of fluid as is shown here.

The pleural fluid will be sent for cell count with differential, anaerobic and aerobic cultures, pleural fluid pH, glucose, LDH, protein, albumen and pleural fluid NT-pro-BNP if congestive heart failure is suspected. Before the syringe is removed, the stopcock will be turned off to the patient and then the syringe can be removed safely and placed to the side while we attach suction tubing onto the catheter tube as is demonstrated here.

An 18 gauge needle attached to the suction tubing will then be inserted into an evacuated container. The stopcock will then be turned open to the container to allow aspiration of pleural fluid into the evacuated container for a therapeutic Thoracentesis. Once we have complete drainage of the pleural space, the Safe-t-Centesis catheter can then be withdrawn out of the skin while the suction continues to pull from the evacuated container.

Once the catheter is removed, a sterile Band-Aid is applied to the insertion site, and then the drape will be removed and the procedure is complete.