Thoracentesis

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Thoracentesis (thoracocentesis) is a core procedural skill for hospitalists, critical care physicians, and emergency physicians. With proper training in both thoracentesis itself and the use of bedside ultrasonography, providers can perform this procedure safely and successfully. [1, 2] Before the procedure, bedside ultrasonography can be used to determine the presence and size of pleural effusions and to look for loculations. [3] During the procedure, it can be used in real time to facilitate anesthesia and then guide needle placement.

Thoracentesis is indicated for the symptomatic treatment of large pleural effusions (see the images below) or for treatment of empyemas. It is also indicated for pleural effusions of any size that require diagnostic analysis. [4, 5, 6]

There are no absolute contraindications for thoracentesis. Relative contraindications include the following:

Uncorrected bleeding diathesis

Chest wall cellulitis at the site of puncture

A 2017 review of literature on preprocedure, intraprocedure, and postprocedure aspects of thoracentesis suggested the following [7] :

Complication rates for thoracentesis performed by experienced clinicians are not available. However, data on complications that develop after thoracentesis performed by residents learning the procedure are available. [1, 8]

Major complications include the following:

Pneumothorax (11% [9] )

Hemothorax (0.8%)

Laceration of the liver or spleen (0.8%)

Diaphragmatic injury

Empyema

Tumor seeding

Minor complications include the following:

Pain (22%)

Dry tap (13%)

Cough (11%)

Subcutaneous hematoma (2%)

Subcutaneous seroma (0.8%)

Vasovagal syncope

Wayne DB, Barsuk JH, O’Leary KJ, Fudala MJ, McGaghie WC. Mastery learning of thoracentesis skills by internal medicine residents using simulation technology and deliberate practice. J Hosp Med. 2008 Jan. 3(1):48-54. [Medline].

Duncan DR, Morgenthaler TI, Ryu JH, Daniels CE. Reducing iatrogenic risk in thoracentesis: establishing best practice via experiential training in a zero-risk environment. Chest. 2009 May. 135(5):1315-20. [Medline].

Koegelenberg CF, Irusen EM, von Groote-Bidlingmaier F, Bruwer JW, Batubara EM, Diacon AH. The utility of ultrasound-guided thoracentesis and pleural biopsy in undiagnosed pleural exudates. Thorax. 2015 Oct. 70 (10):995-7. [Medline].

Porcel JM. Tuberculous pleural effusion. Lung. 2009 Sep-Oct. 187(5):263-70. [Medline].

Wickbom A, Cha SO, Ahlsson A. Thoracocentesis in cardiac surgery patients. Multimed Man Cardiothorac Surg. 2015. 2015:[Medline].

Kenta O, Shoko A, Takeshi I, Satoshi H, Yuji F, Yasushi S, et al. Dependent Lung Tension Pneumothorax During 1-Lung Ventilation: Treatment by Transmediastinal Thoracentesis. A A Case Rep. 2015 Aug 15. 5 (4):61-3. [Medline].

Schildhouse R, Lai A, Barsuk JH, Mourad M, Chopra V. Safe and Effective Bedside Thoracentesis: A Review of the Evidence for Practicing Clinicians. J Hosp Med. 2017 Apr. 12 (4):266-276. [Medline].

Seneff MG, Corwin RW, Gold LH, Irwin RS. Complications associated with thoracocentesis. Chest. 1986 Jul. 90(1):97-100. [Medline].

Celik B, Sahin E, Nadir A, Kaptanoglu M. Iatrogenic pneumothorax: etiology, incidence and risk factors. Thorac Cardiovasc Surg. 2009 Aug. 57(5):286-90. [Medline].

Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. 5th ed. 2009.

Dimov V, Altaqi B. Thoracentesis: A Step-by-Step Procedure Guide with Photos. Clinical Notes. Available at http://note3.blogspot.com/2004/02/thoracentesis-procedure-guide.html. Accessed: July 8, 2008.

Chaiyakunapruk N, Veenstra DL, Lipsky BA, Saint S. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis. Ann Intern Med. 2002 Jun 4. 136(11):792-801. [Medline].

Mark E Brauner, DO Emergency Physician, Eugene Emergency Physicians, PC

Mark E Brauner, DO is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Regina A Bailey, MD, JD, LLM Resident Physician, Department of Emergency Medicine, Baylor College of Medicine

Regina A Bailey, MD, JD, LLM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, Society for Academic Emergency Medicine, Emergency Medicine Residents’ Association, American Bar Association

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

James Quan-Yu Hwang, MD, RDMS, RDCS, FACEP Staff Physician, Emergency Department, Kaiser Permanente

James Quan-Yu Hwang, MD, RDMS, RDCS, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Institute of Ultrasound in Medicine, Society for Academic Emergency Medicine

Disclosure: Received salary from 3rd Rock Ultrasound, LLC for speaking and teaching; Received consulting fee from Schlesinger Associates for consulting; Received consulting fee from Philips Ultrasound for consulting.

Zab Mosenifar, MD, FACP, FCCP Geri and Richard Brawerman Chair in Pulmonary and Critical Care Medicine, Professor and Executive Vice Chairman, Department of Medicine, Medical Director, Women’s Guild Lung Institute, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD, FACP, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society

Disclosure: Nothing to disclose.

Gil Z Shlamovitz, MD, FACEP Associate Professor of Clinical Emergency Medicine, Keck School of Medicine of the University of Southern California; Chief Medical Information Officer, Keck Medicine of USC

Gil Z Shlamovitz, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association

Disclosure: Nothing to disclose.

Thoracentesis

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