Which intercostal space is entered for a thoracentesis

Primary spontaneous pneumothorax Acute pain management Trauma. Thoracocentesis should only be considered after consultation with a senior clinician in patients with:. Analgesia and local anaesthesia are mandatory except with tension pneumothorax which is immediately life threatening. The Royal Children's Hospital Melbourne. Thoracocentesis and chest drain insertion. Attach the small anesthetic syringe to the thoracentesis needle and enter the skin.

Pull back on the syringe as you advance, and when you enter the pleural space, stop advancing. While holding the syringe and needle, advance the plastic cannula covering the needle a few cm. Remove the needle from the cannula, holding a finger on the cannula opening to prevent air from entering. Attatch the large syrine and aspirate fluid from the catheter in the pleural space. Place fluid into collection tubes if indicated for analysis.

If fluid is to be sent for cytology, use plastic bag in kit. Use one-way valve and 60 mL syringe as a pump to fill bag with desired amount. It is best to obtain as much fluid as possible for cytology. Pleurodesis and placement of an indwelling pleural catheter are most commonly done to manage malignant effusions. Pneumothorax Pneumothorax Pneumothorax is air in the pleural space causing partial or complete lung collapse. Pneumothorax can occur spontaneously or result from trauma or medical procedures.

Diagnosis is based on clinical Diagnostic thoracentesis Indicated for almost all patients who have pleural Hemothorax Hemothorax Hemothorax is accumulation of blood in the pleural space. See also Overview of Thoracic Trauma. The usual cause of hemothorax is laceration of the lung, intercostal vessel, or an internal Bloody fluid that does not clot in a collecting tube indicates that blood in the pleural space was not iatrogenic, because free blood in the pleural space rapidly defibrinates.

Appropriate containers eg, red top and purple top tubes, blood culture bottles for collection of fluid for laboratory tests. Ample local anesthetic is necessary, but procedural sedation is not required in cooperative patients. Thoracentesis needle should not be inserted through infected skin eg, cellulitis or herpes zoster. If the patient is receiving anticoagulant drugs eg, warfarin , consider giving fresh frozen plasma or another reversal agent prior to the procedure.

Only unstable patients and patients at high risk of decompensation due to complications require monitoring eg, pulse oximetry, electrocardiography [ECG]. Recumbent or supine thoracentesis eg, in a ventilated patient is possible but best done using ultrasonography or CT to guide procedure.

The intercostal neurovascular bundle is located along the lower edge of each rib. Therefore, the needle must be placed over the upper edge of the rib to avoid damage to the neurovascular bundle. The liver and spleen rise during exhalation and can go as high as the 5th intercostal space on the right liver and 9th intercostal space on the left spleen. The neurovascular bundle located at the lower edge of the rib includes the intercostal vein, artery, and nerve.

Confirm the extent of the pleural effusion by chest percussion and consider an imaging study; bedside ultrasonography is recommended both to reduce the risk of pneumothorax and to increase the success of the procedure 2 References Thoracentesis is needle aspiration of fluid from a pleural effusion.

Advance the needle slowly at a 45 degree angle in the middle of the 7th or 8th intercostal space into the pleural space. A small amount of negative pressure should be applied as the needle passes through the thoracic wall. The needle should be angled downward, parallel to the body wall. The fluid or air should then be aspirated. The needle may need redirecting to access pockets of fluid. Up to mls of fluid per side can be expected in the cat.

Removal of fluid should see an improvement in clinical signs. The following can be analysed: cytology, total cell count, differential cell count, total protein, bacterial culture ans sensitivity, gram stain and triglyceride and cholesterol levels if chylothorax is suspected. The fluid can give an indication of prognosis ; in the cat prognosis is generally poor for all diagnoses except pyothorax an exudate with degenerate neutrophils and intracellular bacteria.

Therefore it is often useful to perform in-house cytology to give a preliminary diagnosis, which allows the owners to make an informed decision before proceeding with further treatment. Differential diagnosis in the cat include congestive heart failure , FIP , pyothorax , neoplasia , haemothorax and chylothorax.