Pleural puncture

Puncture between the two pleural layers.

Indications

Drainage of pleural fluid for exploratory and diagnostic purposes.

Material

The same material as for a lumbar puncture: needle with stylette 20 to 23G.

Technique

Rigorous asepsis: clean the area with large quantities of polyvidone iodine (see table 1), sterilised equipment and sterile gloves if possible.

The patient should be seated, bending forward with hands on knees.
Place a long, large bore needle on a syringe (the wall thickness is about 3cm).

For an exploratory puncture, avoid the cardiac region, the section above the axillary crease, and do not inject below the 9th rib.

Puncture the superior brim of the inferior rib marked with the index finger of the left hand.

Gently advance the needle perpendicular to the surface, while aspirating the syringe, until fluid is collected. If the puncture fails, remove the needle aspirating all the time, and start again in an adjacent space.

In the case of a puncture for drainage of fluid or for diagnostic collection, enter the 8th intercostal space in the posterior axillary line. When the fluid has been collected, connect the needle to a large diameter drainage tube (a perfusion tube) which can be clamped with forceps and attached to a large aspirating syringe (30 to 50mls).

Drainage of fluid must be slow and not more than 700 to 800ml per episode.

ALWAYS ASPIRATE while removing the needle and compress the puncture point with a sterile dressing.

Accidents

· Pulmonary edema and syncope: rarely.

· Pneumothorax created by the entry of air at the time of puncture; prevented by ensuring a tight fit between the needle and syringe and by ensuring that continuous aspiration occurs as the needle is withdrawn.

· Accidental puncture of the vascular/nerve bundles due to a puncture at the inferior rather than the superior border of the rib.