Fluid Management
Procedure Guide
Indications
New-onset or large/symptomatic pleural effusion
Can be diagnostic or therapeutic
Contraindications
Unsafe window for percutaneous access
Uncorrected coagulopathy (INR >2.0)
Pre-procedure Care
Review imaging if available or use US to assess volume and vasculature.
Can continue antiplatelet and anticoagulation.
Procedure
Patient seated on edge of bed leaning over a table to open up the posterior ribs, decubitus with access side down, or supine
Pre-scan and mark spot
Anesthetize the skin, subcutaneous tissues, and pleura.
Advance catheter into the pleural cavity under ultrasound guidance (lots of variation)
Classic is a Yueh needle with straight or pigtail catheter to advance over the needle.
Some kits come with an atraumatic “centesis” needle with catheter for access.
Others will use a Yueh or 19G coaxial needle, advance a working wire, and place a 5 Fr pigtail or 7-8 Fr pigtail drain.
Other directly trocar in a 7-8 Fr pigtail drain to reduce the number of exchanges for patient comfort
Attached tubing to vacuum bottle or wall suction.
Good to not drain too quickly or too much to avoid re-expansion pulmonary edema. Most recommend no more the 1.2 L at one time. Others say 1 or 2 L or until patient begins to cough.
If the effusion is very large, can leave a pigtail drain in place for more gradual drainage overnight.
Remove catheter and achieve hemostasis.
Complications
Pneumothorax (1-3%), re-expansion pulmonary edema, infection, bleeding, and liver/spleen puncture are very rare
Post-procedure care
If diagnostic, send fluid for appropriate studies, e.g., cytology, protein, LDH, triglycerides.
Post-procedure CXR can be helpful to assess for pneumothorax or re-expansion pulmonary edema.