Indications
Diagnostic thoracentesis is shown in all patients with Pleven eral effusion of unknown etiology. In our experience, in diagnostic thoracentesis difficult to produce Aspira tion pleural fluid, if the thickness of the layer to X-ray gram chest when lying on the side is less than 10 mm. Such patients we usually thoracentesis not about tormented. If thoracentesis planned patient with Neboli PWM pleural effusion, it must first be determined accurately casting location pleural fluid using an ultra sound.
Contraindications
The main contraindication to the performance of diagnostic thoracentesis is hemorrhagic diathesis. In addition, it is not recommended to perform thoracocentesis in patients receiving anticoagulants, especially thrombolytic agents. However, if required by the urgency of the situation, a diagnostic thoracentesis can be made to any patient, but in such SLN teas it should be done with a fine needle and with great cautious Nost. A puncture can not be produced in areas with SHOCK skin niyami, such as pyoderma whether or herpes Sha.
The position of the patient with thoracocentesis
During the diagnostic and especially therapeutic thoraco tsenteza and the patient, and the person performing this manipulation should comfortably. Apparently, the most convenient nym is the position of the patient, when he sits on the edge of the AOC vati, hands and head on one or two pillows, premises whelping on the bedside table . For convenience, a stool is placed under the patient’s feet. The bed on which the patient is sitting should be raised so that the doctor does not have to stoop. The patient is seated on the foot end of the bed, the side of the chest cavity with effusion should be races put closer to the foot end of the bed. With this position The patient’s doctor doesn’t have to reach across the bed. That part of the bed on which the patient is sitting close the sterile –
The patient, rec wind blows when performing diagnostic and therapeutic thoracentesis .
diaper. The back of the patient must be in a vertical position to the bottom part hemithorax located ACA di. If the patient is too tilted forward, then sa May lower part of the hemithorax can move kpc mong and behind the liquid does not remain. Sometimes patients are too weak to at hoditsya seated polo zhenii. In such cases thoracentesis can produ dit lying on the side (the affected side down), a back patient dol It is located along the edge of the operating table or bed. Or the patient can be put on a bed, as much as possible having raised its headboard. This put SRI thoracentesis produ DYT medium for podmyshech hydrochloric line.
Selection of puncture site
The puncture site should you Birao carefully. Location fluid op redelyayut of ra- IU chest. However, more precise information about the distribution situation of the liquid gives the physical examination of the patient’s rib cage. In the presence of fluid between the lung and the chest wall there is the loss of tactile detectably of voice tremor and reduction of percussion tones. Punk tion should be carried out in the intercostal space below the place where the border starts losing tactile selected by vote of Vågå jitter and reduce percussion tones. Puncture should be stepping back a few centimeters from a backbone nickname, which is easily palpable ribs. Puncture should produ dit immediately above the rib, as arteries, veins and ner you pass under the ribs (Fig. 50), so the introduction of the needle over the rib minimizes the risk of damage to these structures. To identify the location of the pleural effusion, you can use ultrasound diagnosis or computed tomography. If these methods are used
Subcutaneous injection of local anesthetic through the needle number 25 (A). WWE denie local anesthetic over the ossuary (B). Thoracentesis , ASPI radio pleural fluid (B). The needle is introduced too high into the syringe fall bubbles will repay ha (D). Low insertion of a needle in the syringe the pleural Yid no bone nor air (D).
diagnostic thoracentesis should be performed without changing of Proposition patient. Ideally, after determining the location of the fluid, thoracentesis is immediately produced without moving the patient.
Technique
The materials required to perform diagnostic thoracocentesis are listed in Table. 12. They should be prepara Lena prior to manipulation. The course of manipulation should be downward and benevolent explain to the patient, and from it shall be obtained written consent to its implementation. Some authors to prevent vasovagal reactions is recommended for all patients with atropine , but we usually do not prac tic, because they do not feel like the typical reaction. Od Nako we prepare atropine, and when the first signs of a vasovagal administered to the patient subcutaneously or intra- reaction musculo 1.0 mg atropine. It should also be noted that we do not give the patient tranquilizers, painkillers or sedatives if he does not show excessive excitement. So sick we immediately prior to manipulation vnut Riven introduce diazepam ( Valium ).
The next step is to provide local anesthesia. Anesthesia of the skin, periosteum of the rib and parietal pleura is necessary. Skin Anesthesia is performed by injection through a short needle № 25 sufficient amount of lidocaine (about 0.5 ml) to form a small wave dyr. Then the needle is replaced by a short needle № 22, a length of 3.8 cm. This needle is inserted into the rib periosteum, and then moved up along the edge, is not repeatedly introducing a largeamount (0.1-0.2 ml) lidocaine. When the needle is over the edge, it begins to slowly pro move in the direction of the pleural cavity, producing Aspira tion after administration of 0.1-0.2 ml of lidocaine every 1-2 mm. Such repeated aspiration and the introduction of lidocaine guarantee anesthesia of the parietal pleura. When a syringe containing lidocaine enters pleural Yid bone, the needle is withdrawn from the pleural cavity and connected to a 50- to 60-millimeter syringe containing 1 ml of heparin. Heparin is added to prevent clotting Pleven tral liquid, as in the pleural liquid coagulated It’s difficult to determine the pH and cellular composition. Then, the same needle is introduced again along the same path into the pleural by lethargy with constant aspiration for as long as the syringe starts to enter the pleural fluid. Aspirate continuing out to until the syringe is filled with fluid. Then the needle is removed, which means the completion of the manipulation.
Sometimes, after the needle has been inserted to the end into the pleural cavity, no liquid is drawn into the syringe. In that FIR cases, you should start slow removal of the needle by constant aspiration. In some cases, the layer of fluid may be thin and can be skipped with the introduction of the needle. When introducing or deriving needle pleural fluid into the syringe does not arrive, this means that: 1) the needle to too ROTKO; 2) the needle is inserted too high; 3) the needle is inserted too low; 4) there is no fluid in the pleural cavity. For a patient with muscular or excess supply it at the first attempt air into the syringe is not plucked – a needle (3.8 cm) should be replaced by a longer and repeat pro cedure. If the initial introduction of the anesthetic in the syringe were taken air bubbles, this indicates that the needle has been introduced too high and hit the lung parenchyma. In this case, the procedure should be repeated, changing the puncture to the edge below. There is another vari ant when the first attempt is not received audio bubbles WHO spirit or liquid, which is observed in the case of the introduction of the needle below the optimum point (see. Fig. 50 D), then follows the procedure of blowing repeated, changing the puncture edgewise above . Ass The insertion of a thin needle into the lung is not catastrophic and can rarely cause the development of pneumothorax. A pleural fluid, no matter how thick it may be, can always be aspirated with a needle No. 20 or No. 22.