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TORACOCENTEZA

1. Indicatii
a. Procedura de dg la pac. cu colectie pleurala de cauza necunoscuta
i. Analiza lichidului pleural – categorizata transudat si exudat – vezi
anexa 1
b. Procedura terapeutica
2. Contraindicatii
a. Precautii - med anticoagulanta, coagulopatii, trombocitopenie
b. Extrema precautie- pacientilor cu ventilatie mecanica, ghidaj ecografic
c. Infectii cutanate, leziuni
3. Echipament
a. pachete - materiale necesare
b. Solutie dezinfectanta, pansamente sterile, seringi, ace pt anestezie locala
c. Cateter 18 G, seringi mari de 60 ml, sistem de 3 cai, pansament ocluziv
steril, tub de drenaj, vacuete, recipiente pt lichidul evacuat
4. Pregatire
a. Explica procedura pacientului
b. Obtinerea consimtamantului scris
c. Procedura sterila
d. Pozitia pacientului
i. Pozitie sezanda
5. Locul de insertie
a. Estimare a nivelului lichidului pleural
b. Insertia acului cu 1-2 spatii intercostale, mai jos de nivelul estimat, 5-10
cm de coloana vertebrala
c. Evita lezarea intrabdominala, nu inserati acul mai jos de coasta nr 9
d. Marcheaza locul si apoi se pregateste
e. Anesteziere locala, aspira la fiecare 2-3 mm
f. Evita lezarea nervilor intercostali si vaselor de sange, acul nu trebuie sa
atinga suprafata inferioara a coastei
g. Noteaza adancimea penetrarii acului inainte de extragerea lui
6. Aspirare lichid pleural
a. Ataseaza seringa la cateter, avansare prin aspiratie continua
b. Daca lichidul apare in seringa nu avansam cu acul, se scoate acul si se lasa
cateterul pe loc
c. Ataseaza seringa cu sistemul de 3 cai, se aspira 50 ml si apoi se inchide
d. Atasare la un recipient de evacuare a lichidului pleural
e. Nu > 1500 ml
f. Indepartarea cateterului – tine respiratia la sf expirului, acopera locul de
insertie cu pansament ocluziv
7. Analiza lichidului pleural - vezi anexa 2
a. Vacuete fara aditivi-Proteine si LDH
8. Complicatii
a. Pneumotorax este rara dupa toracocenteza
b. Rx toracic - conditii
c. Durere, tusea, infectie localizata
d. Complicatii serioase
i. Hemotorax, lezare ale organelor intraabdominale, embolie, edem
pulmonar

Anexa 1
Common Causes of Transudative and Exudative Pleural Effusions
Criteria for the Differentiation of Transudates and Exudates.

Transudate
Common causes
Congestive heart failure
Cirrhosis
Nephrotic syndrome
Pulmonary embolism
Criteria for differentiation
Ratio of pleural fluid protein to serum protein <0.5
Ratio of pleural fluid LDH to serum LDH <0.6
Pleural fluid LDH <2/3 upper limit of normal for serum

Exudate
Common causes
Cancer
Pneumonia
Trauma
Tuberculosis
Pulmonary embolism
Rheumatoid arthritis
Systemic lupus erythematosus
Criteria for differentiation
Ratio of pleural fluid protein to serum protein >0.5
Ratio of pleural fluid LDH to serum LDH >0.6
Pleural fluid LDH >2/3 upper limit of normal for serum

Anexa 2 - Additional Tests for the Evaluation of Exudative Effusions.


Test Submission Method
Cell count and differential count EDTA-treated tube
Gram’s stain and culture Syringe for Gram’s stain; culture
bottles for culture
Hematocrit EDTA-treated tube
Glucose measurement Tube without additives
Cytologic profile Syringe or evacuated container
pH Heparinized syringe (e.g., arterial
blood gas syringe) on ice
Triglyceride measurement Check with your laboratory.
Amylase measurement Check with your laboratory.