pleural aspiration procotol

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CDHB Hospital Palliative Care Service May 2008 Review 2010

PLEURAL ASPIRATION PROCOTOL FOR ONCOLGY/ PALLIATIVE CARE PATIENTS

Equipment

Dressing pack

Sterile gloves Skin preparation Solu-IVTM Swabstick (Chlorhexidine 2% and Alcohol 70%)

1x10ml and 1x50ml syringe

26G and 22G needles

2 x 5ml amps 1% plain Xylocaine

3 way stop cock

Size 14G and size16G 45mm Instye IV catheter IV giving set

1 pack sterile gauze squares and/or swabs

1 sterile dressing sheet (included in dressing pack)

MicroporeTM

tape and gauze squares for padding and securing catheter 2 x large TegadermTM dressings

Paper bag Sharps box

Sticky plasterAdditional Equipment that may be required

2 specimen pottles

Contraindications Absolute contraindications include an uncorrected coagulopathy, cardiac,

haemodynamic or rhythm instability, unstable angina or respiratory distress notattributed to the pleural effusion

Relative contraindications include lack of patient co-operation, mechanical ventilation,bullous lung disease and local chest wall infection

Occasionally, due to frailty or poor overall condition, it may be inappropriate to performthe procedure as an outpatient and the patient must be admitted.

Procedure

Most patients will have had an USS and x marks the spot performed and a suitablesite for aspiration will have been marked on the skin. This is especially useful if thefluid is loculated, and should give you a guide as to the volume and depth of fluid. If no

USS has been performed, obtain a lateral decubitus chest x-ray to confirm thepresence of free fluid - pleurocentesis may be performed safely if 10mms of free fluid isidentified on lateral decubitus chest x-ray.

The position of the effusion should be confirmed by percussion and the side doublechecked on the PA CXR.

Explain the procedure to the patient, verbal consent is satisfactory.

Position the patient in a chair, leaning forward with the arms on a pillow on a bed orwith the patient sitting backwards on a chair with their arms on a pillow over the back ofthe chair.

Using percussion and vocal resonance locate the upper limit of the effusion and thearea of maximal dullness overlying the known location of the effusion. If an ultrasound

has been used to identify the effusion position the patient in the same way as for theultrasound.


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The needle is generally inserted at the mid scapula line unless an alternate site hasbeen identified on ultrasound - the site of the aspiration should be 1 - 2 intercostalspaces below the top of the effusion in the mid scapula line.CAUTION - the liver may be situated at the 9th intercostal space on the right

Using aseptic technique:1. Infiltrate with local anaesthestic using 26G needle followed by the 22G needle until-

pleural fluid is aspirated.2. A 10-20ml syringe is attached to the Insyte catheter - the needle is inserted over

the superior rib margin avoid the lower border of the upper rib to prevent damageto the subcostal neurovascular bundle.

3. Gentle suction is applied to the syringe while the cannula is advanced - once fluidflows back into the syringe the needle should be partially removed (to prevent lungpuncture) and the cannula advanced.

4. The syringe and the needle should be removed, a gloved fingertip applied over theopen cannula and a closed three way stop cock attached to the cannula.

5. The cannula should be securely attached to the chest wall using micropore tapewith a gauze square for padding if necessary. The two TegadermTM dressings are

then used to sandwich the catheter to the chest wall.6. A giving set is pushed firmly into the top of a catheter bag and the free end attached

to the stop cock.7. The stop cock is opened and fluid should flow into the bag.8. If fluid does not flow attach a 20-50ml syringe to the free port on the stop cock and

aspirate up to 50mls this should allow flow to start due to siphoning.

Terminating the procedure

Aspiration should be stopped when 1000-2000mls has been removed, depending onthe patient's size - removal of larger quantities puts the patient at risk of re-expansion

pulmonary oedema. If cough develops, the procedure should be suspended temporarily until coughingresolves. If coughing continues or the patient feels new chest discomfort (possiblyindicating mediastinal shift) the procedure should also be abandoned.

To stop draining, close the stop cock and remove the cannula on expiration to reducethe risk of pneumothorax - an air-tight dressing or plaster is then applied. (The nursesroutinely do this).

Patients routinely have a CXR post-removal of the catheter, which should be reviewedprior to the patient leaving the hospital.

If concerned, examine the patient for the possibility of pneumothorax by checking thatthe trachea is central and that there is good air entry particularly at the apices - if air

entered the pleural space during the procedure or if there is any doubt obtain anurgent CXR to check for pneumothorax.

Haemorrhage should not be a problem provided the needle is not inserted near thelower rib margin where the neurovascular bundle is situated.

Air embolism is rare but catastrophic complication.

Specimen collection

Diagnostic specimens may be sent to the laboratory. It may be useful to send a largevolume of fluid (up to 500mls) particularly attempting to prove malignancy. CanterburyHealth Laboratories should be consulted for the specifics of sample collection inindividual cases.


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Post-care

Pulse and BP should be performed if the procedure is stopped due to adverse effectsor if the patient feels unwell in any way.

Puncture site bleeding can be a complication - haemostasis is usually achieved whenpressure is applied to the area.

A significant pneumothorax will need expert management by the Respiratory

Physicians. The patient should remain in the department for 30 minutes after the procedure is

completed and must not drive him/herself home.

The patient must be advised who to contact during and after working hours shouldcomplications develop.

Documentation

The amount of fluid drained should be recorded in the Oncology Notes as well as in theHospital Clinical Records (if performed in the DSU). Note also whether problems orcomplications were encountered, including relevant recordings.

pleural aspiration procotol

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