Procedure for THORACENTESIS: Position of Patient: High Fowlers with legs hanging at the side of the bed.

The patient is to lean forward and to rest the arms on a table adjusted to the height of the the patients elbow Rationale: This position moves the scapulae anterolaterally, exposing most of the patients back. If sitting position cant be done, a lateral approach is selected: patient is propped up with a rolled towel placed lengthwise beneath the back with upper arms resting over the ear. Rationale: This position opens up the intercostal spaces. Alternative positions and areas are chosen when pleural effusion is loculated to provide for successful evacuated of loculated fluid. 1. After review of the old and new chest radiographs, thoracentesis can be perfomed. The fluid level is first percussed and the ribs in the region are palpated to identify the intercostal space through which the needle will be inserted. - The most appropriate site is the 7th intercostal space. (The site is localized by palpating the tip of the scapula with the patient sitting upright.) 2. Patient is prepped and draped. 3. Local anesthetic (e.g 1% lidocaine) is used to raise a wheal in the epidermis. - The most important point of view of the patient is that the procedure should be painless. 4. Pain is avoided by further advancing the needle and anesthetizing the periosteum over the 8 th rib, as well as the parietal pleura in the 7th intercostal space. - This is done by infiltrating the subcutaneous tissues and then guiding the needle over the superior margin of the 8th rib, remaining perpendicular to the rib. *DAMAGE TO THE INTERCOSTAL NEUROVASCULAR BUNDLE can be PREVENTED by maintaining a PERPENDICULAR ORIENTATION. The intercostals neurovascular bundle is located in the inercostal groove of the 7th rib. 5. At the level of the rib, infiltration of the tissue is alternated with aspiration with the syringe to ascertain when the pleural space has been reached. 6. Once fluid has been aspirated confirming that the needle has reached the pleural space, the needle is slowly withdrawn while a further 2 to 3 ml of local anesthesia is injected. - if procedure is done correctly, the parietal pleura will be well anesthetized. * IF FLUID CANNOT BE ASPIRATED, the attempt should be made to ANESTHETIZE AND ASPIRATE ONE INTERCOSTAL SPACE LOWER. THE RECOMMENDATION HOWEVER IS TO GO NO LOWER THAN THE 8TH INTERCOSTAL SPACE due to the risk of lacerating the LIVER (right) or the SPLEEN (left)-> lies adjacent to the bed of ribs 9 to 11.

7. Thoracentesis catheter inserted into the pleural space. - the catheter should be kept perpendicular to the chest wall to avoid inaverdent injury to the intercostals neurovascular bundle of the 8th rib. 8. Fluid is removed into a 60ml syringe and injected into a sterile bulb or bottle connected to the catheter with a stop-cock. 9. A CHEST RADIOGRAPH should be obtained subsequent to any attempt at thoracentesis. - to check for the presence of either a pneumothorax or residual fluid collection.