Healthcare and Medicine Reference
In-Depth Information
Parietal
pleura
Rib
Rib
Vein
Artery
Nerve
Neurovascular
bundle
External
Intercostal
muscles
Innermost
intercostal
Internal
Needle
Figure 9.3 Equipment for performing a diagnostic pleural aspiration.
you should be able to aspirate pleural fl uid with the full length of
a green (21G) needle.
(a)
(b)
Figure 9.2 (a) The anatomy of the intercostal nerves and vessels.
(b) Insertion of needle over rib to avoid damage to neurovascular bundle.
Diagnostic pleural aspiration (tap)
For a diagnostic pleural tap attach a green needle to the 50-mL
syringe and insert the needle through the area of skin which has been
anaesthetised (Figure 9.4c). Again, the needle should be inserted just
above the upper border of the rib. Aspirate 50 mL of pleural fl uid
then withdraw the needle and apply a dressing to the site.
Box 9.1 Equipment for diagnostic pleural aspiration
Dressing pack and solution (we recommend 2% chlorhexidine in
70% isopropyl alcohol) for cleansing of the skin
Sterile gloves and gown
Therapeutic pleural aspiration (Figures 9.5 and 9.6)
Some hospitals have ready-made pleural aspiration packs.
Otherwise, in addition to the equipment listed in Box 9.1 you
will need:
large-bore IV cannula - 14G (brown/orange) or 16G (grey)
1 or 2% lidocaine
10-mL syringe for local anaesthetic
One blue needle
Two green needles
50-mL syringe
three-way tap
Specimen containers as clinically indicated, usually three white top
IV giving set
universal containers, one glucose (fl uoride oxalate) bottle, ABG
syringe, blood culture bottles
Skin dressing for post procedure
sterile container/bag for collection of fl uid.
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Initially verify that the insertion site is correct by aspirating fl uid
with a green needle. If unable to aspirate fl uid with a green nee-
dle then get an ultrasound of the chest to confi rm the location
of fl uid and ask the radiologist to leave a mark on the skin.
When the position has been confi rmed, insert the large-bore
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Firstly confi rm the site and size of the pleural effusion by clinical
examination and review of the chest X-ray (CXR).
Ideally ask the patient to sit on the edge of their bed and lean for-
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2
cannula into the area of skin that has been anaesthetised until
a fl ashback of pleural fl uid is seen. Then withdraw the needle
whilst advancing the cannula into the pleural space. As the
needle is withdrawn, place your sterile-gloved thumb over the
end of the cannula to prevent air entering the pleural cavity.
Attach the three-way tap to the end of the cannula and attach
wards placing their elbows onto a pillow placed on the bedside
table. Alternatively sit the patient up in bed.
Percuss the chest posteriorly to determine the level of the
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effusion. Mark a site on the posterior chest wall medial to the
angle of the scapula and one intercostal space below the upper
limit of dullness to percussion.
Use a strict aseptic technique. Wear sterile gloves and gown and
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the 50-mL syringe to the opposite port (Figure 9.4d).
Attach the IV giving set to the side port of the three-way tap and
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4
place the other end of the giving set into the sterile container or
bag for collection of the pleural fl uid.
Aspirate the pleural fl uid 50 mL at a time, moving the three-
consider face mask with visor.
Prepare the skin with antiseptic solution and allow to dry, and
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apply a sterile drape (Figure 9.4a).
Infi ltrate the skin with local anaesthetic using a blue (23G)
way tap to empty the syringe into the container or bag. Do not
remove more than 1.5 L of fl uid due to the risk of re-expansion
pulmonary oedema.
At the end of the procedure ask the patient to breathe out,
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needle or orange (25G) needle (Figure 9.4b). Then use a green
needle (21G) to infi ltrate deeper. The needle should be inserted
just above the upper border of the rib to avoid the intercostal
neurovascular bundle. Always aspirate before injecting local
anaesthetic to ensure that you are not in a blood vessel. Usually
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remove the cannula and apply a dressing to the site.
Request a chest X-ray post procedure.
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