home Audience 2 Indications and technique for performing thoracentesis and drainage of the pleural cavity. Techniques Thoracentesis and drainage

Indications and technique for performing thoracentesis and drainage of the pleural cavity. Techniques Thoracentesis and drainage

One of the problems in veterinary medicine in cats and dogs is diseases of the chest cavity, in which free fluid accumulates, resulting in respiratory failure and hemodynamic disturbances.

One of these diseases is chylothorax– pathological accumulation of lymph in the chest cavity.

Chylothorax has clinical, radiological and pathomorphological features of the manifestation of pathology similar to other types of diseases in which effusion occurs in the pleural cavity, a displacement of the mediastinum is created and an obstacle to the normal expansion of the lungs.

Among exudative pleurisy in cats and dogs, chylothorax ranges from 0.7 to 3%, and neoplastic and viral manifestations range from 12 to 64%.

There are several etiological and pathogenetic factors leading to the development of the disease.

Trauma is a rare cause chylothorax in cats and dogs, the thoracic duct is quickly restored, and effusions resolve without treatment within 10-15 days.

Chylothorax may occur due to diffuse lymphatic abnormalities, including intestinal lymphangiectasia or generalized lymphangiectasia with subcutaneous lymphatic leakage.

Dilatation of lymphatic vessels (thoracic lymphangiectasia) with exudation of lymph into the chest cavity may be a reaction to increased lymph formation in the liver or lymphatic pressure due to increased venous pressure.

Sometimes a combination of two factors is noted: an increase in lymph volume and a decrease in drainage into the venous collectors.

Possible causes of chylothorax are neoplasms in the cranial part of the mediastinum (lymphosarcoma, thymoma), fungal granulomas, venous thrombosis and congenital anomalies of the thoracic lymphatic duct.

In most animals, despite careful examination, the underlying cause of chylothorax remains unclear (idiopathic chylothorax).

Diagnosis and choice of treatment methods for sick animals with chylothorax remains a pressing and difficult task to this day.

In the domestic literature there is very little material devoted to the clinic, diagnosis (morphology), conservative and surgical treatment of chylothorax in dogs and cats.

Late diagnosis of the disease, and the existing tactics of an exclusively conservative approach to treatment of chylothorax with pronounced clinical manifestations, it leads to prolongation of the pathological process, the result of which will be the development of irreversible changes in the pleura of the lung (fibrosing pleurisy).

Standard methods of conservative (thoracentesis, anti-inflammatory therapy) and surgical (thoracoabdominal, thoracovenous drainage, pleurodesis, thoracic duct ligation) are currently promising methods for treating this pathology, but success (relapse-free course) is 40–60%.

The purpose of the work is to evaluate the results of surgical treatments for chylothorax using various methods.

Materials and methods. The material consisted of 60 animals (cats) diagnosed with chylothorax, and which were subjected to surgical treatment in the period from 2002 to 2010. Surgical treatment included: ligation of the thoracic lymphatic duct n-13, pleuroperitoneal shunting n-9, ligation + pleurodesis n-25.

In 13 animals, diagnostic thoracoscopy revealed fibrosing pleurisy and surgical treatment was refused.

All animals were subjected to clinical and additional diagnostic methods.

The clinical method of the study involved the collection of anamnestic data on the timing and duration of manifestations of breathing disorders.

Particular attention was paid to visual assessment of the external manifestations of disturbances in the respiratory movements of the chest, the degree and type of shortness of breath.

Clinical manifestations of the disease at almost all stages were characterized by: difficulty breathing and shortness of breath - the main symptom of effusion into the pleural cavity. Dry non-productive cough.

Thoracentesis, radiography, morphological examination of the material obtained from the chest cavity, clinical and biochemical blood tests, ECG, ECHO CG, and thoracoscopy were used as additional research methods.

X-ray examination of animals

X-ray examination of the chest cavity was performed using two mutually perpendicular projections, lateral and direct (dorso-ventral).

Typically, the x-ray picture was characterized by total darkening with characteristic signs of the presence of fluid in the chest cavity and caudo-dorsal displacement of the caudal lobes of the lungs. The shadow of the heart silhouette is partially or completely erased, the usual sharp angles of the costophrenic junction are absent (Fig. 1a, b).

Thoracentesis and differential morphological examination

Thoracentesis (pleural puncture) was performed for diagnostic and therapeutic purposes.

Pleural puncture was performed in the 7-8th intercostal space along the line of the osteochondral junction on the left and right, focusing on the cranial edge of the next rib.

After pleural puncture, the pathological contents of the pleural cavity were evacuated and subjected to subsequent examination.

In case of chylothorax, transudate was determined to be milky white or mixed with a small amount of blood. During centrifugation, the exudate generally did not form a sediment (the sediment is represented by blood elements); a biochemical study indicated a large amount of triglycerides characteristic of chylothorax.

Separately differentiated from pseudochylous effusions (rarely found in animals) by the content of cholesterol and triglycerides.

All punctures from the pleural cavity were subjected to microscopic cytological examination, where purulent and neoplastic processes were excluded.

Thoracoscopy was performed under general anesthesia for detailed visualization of the condition of the lungs and neoplasms in the cranial mediastinum. (Fig. 2).
Surgery

Surgical treatment of chylothorax involved surgical intervention under conditions of general anesthesia and artificial ventilation, both open and endoscopic (thoracoscopy).

Pleuroperitoneal (passive) shunting Operation stages:

3. Using a linear approach from the middle of the chest in the caudal direction to the umbilical region, the skin, subcutaneous tissue, and muscles were dissected. An entrance to the thoracic region was provided through the angle of the diaphragm in the area of the xiphoid process. The perihepatic space was freed from adipose tissue and omentum. Silicone drainage was implanted to the communication between the chest and abdominal cavities, followed by fixation of the drainage in the tissues of the diaphragm. The surgical wound was sutured in layers (Fig. 3 a, b).

The purpose of this technique is to create a message and the possibility of outflow of chylous exudate into the abdominal cavity, where it is subsequently absorbed and lymph is recirculated in the body.

Pleurodesis

Operation stages:

1. Fixing the animal on its back.

2. Treatment of the surgical field using generally accepted methods.

3. A mini-access in the area of the xiphoid process is used to access the chest cavity; depending on the stage of the pathological process, partial pleurectomy or targeted treatment with chemicals is carried out under endoscopic control.

The purpose of this surgical intervention is to create adhesive inflammation of the lungs in an expanded state.

Open ligation of the thoracic lymphatic duct

Operation stages:

1. Fixation of the animal in a lateral position.

2. Treatment of the surgical field using generally accepted methods.

3. Access was made to the chest cavity on the left or right in the area of the 8-10 intercostal space with layer-by-layer tissue dissection (skin, subcutaneous tissue, muscles). After access to the chest cavity, surgical access to the abdominal cavity was carried out nearby, a part of the mesentery and intestine was isolated for the purpose of lymphography using a visceral lymphatic collector.

4. Lymphography was performed with a 1% solution of methylene blue with a volume of no more than 0.5 ml injected into the lymphatic vessel. The contrast agent entered the lumbar cistern and stained the thoracic lymphatic duct (Fig. 4a, b).

Under visual control, a ligature made of non-absorbable suture material Prolene 4-0, 5-0 was applied to the visible thoracic lymphatic duct through the access of the thoracic cavity. The surgical wound was sutured in layers.

The purpose of this technique was to stop the flow of lymph through the thoracic lymphatic duct into the chest cavity.

Closed ligation of the thoracic lymphatic duct

Unlike open ligation, closed method involves ligation of the thoracic lymphatic duct using the endoscopic method (thoracoscopy) without wide access to the chest cavity (Fig. 5a, b, c).

Thoracic duct ligation and pleurodesis

This type of surgical intervention involves the use of two methods described above simultaneously - ligation and pleurodesis.

The purpose of this technique is to combine two methods: stopping the flow of lymph through the thoracic lymphatic duct into the chest cavity and creating an adhesive inflammation of the lung and parietal pleura. After which the lung assumes a straightened position in the chest cavity, and in cases of recurrent chylothorax, the possibility of its collapse is reduced. The risk of respiratory failure is sharply reduced.

We used open and endoscopic ligation of the thoracic lymphatic duct.

Postoperative treatment included monitoring the possible consequences of thoracic surgery. Conducting a course of antibiotic and anti-inflammatory therapy. The course of antibiotic therapy was five days, the sutures were removed on the tenth day, after endoscopic manipulation on the third.

Result and discussion

In assessing the results of treatment, great importance was given to data from subsequent clinical observation of operated animals over a period of ten days to one and a half years. (see table).

Results and methods of surgical treatment. Table

The criteria were not only the clinical condition, but also radiographic methods (Fig. 6a, b.).

The prognosis for chylothorax, according to many authors, is extremely restrained. When choosing treatment methods, they study the cause of the disease and begin treatment with conservative therapy methods; in the absence of positive results, they proceed to surgery. We have not achieved long-term positive drug treatment in any animal.

In our opinion, the beginning of surgical treatment is rather arbitrary, and the timing of the development of fibrosing pleurisy is unpredictable. In some cases, we noted the development of fibrosing pleurisy two to three weeks after the onset of clinical signs and did not see them after five months of the disease (video, Fig. 7).

According to our observations, the isolated method of ligation of the thoracic lymphatic duct recurred in six cases; in two animals, repeated surgical intervention was performed to the extent of ligation and pleurodesis (Fig. 8a, b).

The surgical method of bypassing the chest and abdominal cavity was usually complicated by catheter occlusion after surgery. Another disadvantage is the reverse flow of contents when using valveless catheters.

The most effective method was a combination of ligation and pleurodesis. The rehabilitation period was slightly reduced in animals that underwent endoscopic ligation using thoracoscopic techniques when applying a ligature to the thoracic lymphatic duct.

conclusions. According to our observations, true chylothorax in cats does not respond to conservative therapy. The presented results of surgical methods for treating chylothorax in cats allow us to draw conclusions about the need for surgical treatment. The use of combined surgical methods makes it possible to achieve complete or long-term remission of the disease.

Literature.

1. Vorontsov A.A., Shchurov I.V., Larina I.M. Some features and results of operations on the thoracic organs in cats and dogs. Vet clinic. 2005 No. 11(42), 15-17.

2. Birchard S.J., Fossum T.W. Chylothorax in the dog and cat. Vet clin NorthAm Small Anim Pract. 1987 17, 271-283

3. Birchard S.J., Ware W.A. Chylothorax associated with congestive cardiomyopathy in cat. JAT Vet MedAssoc. 1986 189, 1462 - 1464.

4. Birchard S.J., Smeak D.D., McLoughlin M.A. Treatment of idiopathic chylothorax in dogs and cats. J AT Vet Med I 1998 212, 652-657.

5. Breznock EM: Management of chylothorax: Aggressive medical and surgical approach. Vet Med Report 1:380.

6. Forrester S.D., Fossum T.W., Rogers K.S. Diagnosis and treatment of chylothorax associated with lymphoblastic lymphosarcoma in four cats. J AT Vet MedAssoc. 1991 198, 291-294.

7. Sturgess K. Diagnosis and management of chylothorax in dogs and cats. in Pract. 2001 23, 506-513.

8. Thompson M.S., Cohn L.A., Jordan R.C. Use of routine for medical management of idiopathic

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

The procedure involves puncturing 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 a therapeutic value, and subsequent laboratory testing 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 surgery, etc. The accumulation of air (pneumothorax) leads to an increase in pressure in the pleural cavity and, as a consequence, to dysfunction of the chest organs, primarily the lungs. The respiratory mechanism is inhibited.

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

It is assigned to resolve the following problems:

pneumothorax;
postoperative drainage;
post-traumatic drainage;
empyema of the pleura.

Pneumothorax often occurs as a result of injury to the lung by a fragment of rib bone. In this case, air from the lung begins to enter 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 on all patients, or may be prescribed for so-called limited indications. Contraindications include:

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

Carrying out and possible complications of the procedure

To carry out the procedure, the patient must take a sitting position, leaning forward and leaning on any support. First of all, the doctor determines the location for inserting the trocar. In order to reduce pain, this area of the 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, thoracentesis 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.

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

After taking a puncture, a tube corresponding to the nature of the extracted substance is inserted into the hole. The tube is secured with a suture to the chest wall and additionally secured with a bandage. To prevent air from flowing in the opposite direction through the tube into the pleural cavity, it is connected to a water container. Next, you need to check whether the tube was installed correctly and its position in the cavity. For this purpose, the patient undergoes an X-ray examination.

The tube should be removed only after the situation has returned to normal and the cause that led to thoracentesis has been eliminated. A number of indicators indicate that such a state has arrived.

With homothorax, for example, this indicator is the volume of discharge, reduced to an average daily 100 ml. The tube is removed at the moment of strong exhalation, after which the hole is closed with oil-soaked gauze. The fat film prevents air from entering.

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

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

It should be noted that such negative consequences are recorded extremely rarely. In exceptional cases, even death may result from an air embolism.

In order to avoid such complications, as well as to increase the effectiveness of the procedure, the patient is first prescribed an x-ray examination.

As a result, the doctor can determine the size and position of the sinus that is 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 must be taken into account that complications arise after any, especially invasive, intervention, but the need for such manipulations is higher than the risk of possible undesirable consequences.

Indications. Pleural effusion of unknown etiology, detected radiographically, is the most common indication for pleural puncture; it is especially necessary if exudative effusion is suspected. Patients with transudates usually do not undergo thoracentesis, except in cases of suspicious effusion, when it is necessary to ensure that there is no other reason for its appearance, except for an increase in hydrostatic pressure or a decrease in oncotic pressure. Thoracentesis is indicated for infections of unknown origin or ineffective antimicrobial therapy. It is rarely necessary for simple parapneumonic effusions if the patient is improving. Analysis of pleural effusion is important for diagnosis and staging of suspected or known malignancy, as well as for unusual causes of fluid in the pleural cavity (eg, hemothorax, chylothorax, or empyema), since additional invasive treatment is usually required in these cases. Sometimes it is necessary to examine effusion that occurs due to systemic diseases (for example, collagenosis).

Therapeutic indications. Thoracentesis is used to eliminate respiratory failure caused by 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. Thoracentesis can be performed on various parts of the chest depending on the indications (see the terms Drainage of the pleural cavity, “Thoracotomy”). If it is necessary to perform thoracentesis of the lateral chest wall, the patient is placed on the healthy half, under which a cushion 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, thoracentesis should be performed with the patient in a semi-sitting position.

After treating 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 is performed. Advancement of the needle further should be accompanied by continuous injection of novocaine solution. When the pleura is punctured, 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 this, 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 moving the syringe piston 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 into 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 using this method, the SKIN is cut and the soft tissues are pushed apart and a trocar or clamp is inserted into the pleural cavity, depending on the purpose of thoracentesis. If after this manipulation a drainage is inserted 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 removing 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 closed with 1-2 stitches, after which an aseptic bandage is applied.

Drainage of the pleural cavity, or thoracentesis, is prescribed if the patient has accumulated fluid or excess air inside this cavity. The operation involves inserting a special drainage tube through the pleural cavity to remove air or fluid.

With careful drainage, the risk of complications is reduced to a minimum, and many potentially life-threatening diseases can be cured.

The chest tube is inserted by a doctor who is well versed in the technique of this procedure. But in emergency cases, thoracentesis can be performed by any doctor who knows the technique. To place the tube, Kelly clamps or hemostatic clamps, a chest tube, sutures and gauze are used.

No special preparation of the patient for the procedure is required, only in some cases sedation is necessary - one of the anesthesia techniques that allows the patient to more easily endure unpleasant medical procedures.

The main indications for drainage are accumulations of exudate (fluid formed during inflammatory processes), blood or pus. Additionally, indications for drainage may be the accumulation of air between the lobes of the pleura. The cause of accumulation can be various diseases or pathological conditions:

hemothorax, pneumothorax;
pleural empyema;
drainage after surgery.

Pneumothorax, which is spontaneous, usually develops in young people after the alveoli in the upper part of the lung rupture. In older people, this disease develops due to rupture of the alveoli due to emphysema. The cause may also be injuries received during transport accidents, as they are often accompanied by closed injuries and pneumothorax.

Traumatic pneumothorax in most cases is caused by rib fractures. For example, during a fracture, a rib can injure the lung, from which a certain volume of air escapes, and a tension pneumothorax develops.

The need to drain the pleural cavity in pneumothorax occurs when symptoms of a severe form of the disease appear: emphysema, respiratory failure.

Drainage of the pleural cavity is necessarily carried out in case of pleural emphysema - this is one of the absolute indications for surgery. Treatment of emphysema does not depend on the causes of the disease. Therapeutic measures are reduced to gluing the layers of the pleura and early drainage of the resulting fluid. Thoracentesis can be complicated in some cases, for example, if pockets of fluid have formed. Then surgical intervention will be required for complete cure.

After thoracentesis, the patient is prescribed treatment. In this case, the choice of drug depends on the type of emphysema causative agent and the degree of its resistance to drugs.

Drainage of the pleural cavity in case of emphysema does not always give results in the formation of a bronchopleural fistula or pleural cords.

Another indication for drainage is the operation performed. Drainage of the pleural cavity after surgery is carried out to completely eliminate fluid and maintain optimal pressure. If the lung was not damaged during the operation, one perforated drain is installed in the midaxillary line, under the diaphragm. If the lung has been damaged or lung tissue has been resected, two drains are installed in the pleural cavity.

Manipulation technique

For pleural drainage, tubes are used: synthetic or rubber. Most often, the technique involves the use of a rubber tube 40 cm long, which has several holes at the end.

Premedication with opiates is prescribed 30 minutes before thoracentesis. The patient should be in a sitting position, leaning slightly forward and leaning on a chair or table.

Next, mark the location of the tube. If drainage of the pleural cavity is carried out for pneumothorax, then the tube is installed in the fourth intercostal space. In other cases - in the fifth or sixth. The skin is treated with an antiseptic drug. First, a test puncture is carried out - it is designed to confirm that there really is air or other foreign matter in a given place: pus, blood, etc. Specialists perform a test puncture in a medical facility.

After the puncture, a tube is selected, the size of which is determined by the type of substance that needs to be removed:

large - for draining pus and blood;
medium – for serous fluid;
small - to remove air.

After the puncture procedure, the drainage tube is directed through the tract into the chest cavity and closed with a purse-string suture. The tube is sutured to the chest wall and secured with a bandage.

The chest tube is connected to a water container that does not allow air into the chest cavity; the effusion will occur without aspiration (in empyema) or with aspiration (in pneumothorax). After installing the tube, it is necessary to check the correctness of its position; for this, the patient is sent for radiography.

Possible complications

The tube is removed only after the condition that served as an indication for its installation has resolved. To remove the tube for pneumothorax, it is first left in a water container for a while to allow the lung to expand after it is removed.

When removing the tube, the patient should take a deep breath and then exhale as forcefully as possible. The tube is removed when you exhale. The area where the tube was is covered with oiled gauze to avoid the development of pneumothorax. If the indication for drainage is hemothorax or effusion, the tube is removed after the amount of discharge is reduced to 100 ml daily.

Some complications may occur after thoracentesis. In some cases, infection begins due to incomplete removal of pus or its re-accumulation.

Thoracentesis is the main procedure for intensive care and emergency medicine physicians in intensive care units. Ultrasonography may be performed before the procedure to determine the presence and size of pleural effusions, as well as their location.

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

Thoracentesis is intended for the symptomatic treatment of large pleural effusions or for the treatment of empyema. The procedure is also necessary for pleural effusions of any size that require diagnostic analysis.

Transudate effusions occur due to a decrease in plasma and result from a decrease in plasma oncotic pressure and an increase in hydrostatic pressure. Heart failure is the most common cause, followed by liver cirrhosis and nephrotic syndrome.
Exudate effusions result from local destructive or surgical processes that cause increased capillary patency and subsequent exudation of intravascular components into potential sites of disease. Causes are varied and include pneumonia, dry pleurisy, cancer, pulmonary embolism, and numerous infectious etiologies.

There are no absolute contraindications for thoracentesis.

Relative contraindications include the following:

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

Attention

Before performing thoracentesis, it is important to pay attention to the patient's consent and expectations for the procedure, as well as possible risks and complications.

Consent for thoracentesis must be obtained from the patient or family member. It is necessary to make sure that they have an understanding about the procedure so they can make an informed decision.

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

Before performing a thoracentesis procedure, it is necessary to analyze which of the above risks can be avoided or prevented (for example, positioning the patient in such a way that he remains as still as possible during the procedure).

Thoracentesis kit: basic list of materials

There are several special medical devices specifically designed to perform the thoracentesis procedure.

Range of kits for thoracentesis GRENA (UK)

0204-01SN	Thoracentesis/paracentesis set 01SN - Puncture needle - 3 pcs. - Three-way tap - Syringe Luer Lock 60 m	Sterile - 24 pcs.
0204-02SN	Thoracentesis/paracentesis set 02SN - Puncture needle - 3 pcs. - Connecting tube with Luer Lock ports at the ends. - Check valve - Graduated 2 liter bag with drain. - Syringe Luer Lock 60 m	Sterile - 24 pcs.
0204-01VN	- Veress Needle - Connecting tube with Luer Lock ports at the ends. - Three-way tap - Graduated 2 liter bag with drain. - Syringe Luer Lock 60 m	Sterile - 24 pcs.
0204-02VN	Thoracentesis/paracentesis set 01VN - Veress Needle - Connecting tube with Luer Lock ports at the ends.	Sterile - 24 pcs.

Thoracentesis: technique for performing the main procedure and draining the pleural cavity

Preparation for the procedure includes appropriate anesthesia and proper positioning of the patient.
In addition to local anesthesia, general anesthesia with lorazepam may be considered to help manage any pain.

During thoracentesis, analgesia is a critical component., since in its absence complications may develop. 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 parietal pleura, because puncture of these tissues is accompanied by the most acute pain.

Pleural fluid is often obtained through anesthetic penetration into deeper structures, which will help guide needle placement.

The most favorable position for patients to perform thoracentesis is sitting, leaning forward, with their head resting on their 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 remain in this position are placed horizontally on their back.

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

Technique for performing thoracentesis

Ultrasonography. After the patient has been seated, ultrasonography is performed to confirm the pleural effusion and assess its size and location. Next, determine the most optimal puncture site. For ultrasonography, either a curved transducer (2-5 MHz) or a high-frequency linear transducer (7.5-1 MHz) is used. The aperture must be explicitly defined. It is important to choose an intercostal interval in which the diaphragm will not rise during 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 noted as a wave.

Ultrasonography- a useful study for thoracentesis, 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 largest pocket of fluid superficial to the lung, identifying the airway of the diaphragm. Traditionally, this area is located between the 7th and 9th ribs.

Diagnostic analysis of pleural fluid

The pleural fluid is labeled and sent for diagnostic testing. If the effusion is small and contains a large amount of blood, the fluid is placed in the blood tube with an anticoagulant so that the mixture does not thicken.

The following laboratory tests should show the following points:

pH level;
gram coloring;
cell number 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.

Exudative type pleural fluid can be distinguished from transudative pleural fluid in the following cases:

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

There are no complications when performing thoracentesis, but they may develop after the procedure.

The main complications after the thoracentesis and drainage procedure:

Minor complications include the following: