PLEURAL ASPIRATION PROCOTOL FOR ONCOLGY/ PALLIATIVE CARE PATIENTS

Equipment
 Dressing pack
 Sterile gloves
 Skin preparation – Solu-IVTM Swabstick (Chlorhexidine 2% and Alcohol 70%)
 1x10ml and 1x50ml syringe
 26G and 22G needles
 2 x 5ml amps 1% plain Xylocaine
 3 way stop cock
 Size 14G and size16G 45mm Instye IV catheter
 IV giving set
 1 pack sterile gauze squares and/or swabs
 1 sterile dressing sheet (included in dressing pack)
 MicroporeTM tape and gauze squares for padding and securing catheter
 2 x large TegadermTM dressings
 Paper bag
 Sharps box
 Sticky plaster
Additional Equipment that may be required
 2 specimen pottles

Contraindications
 Absolute contraindications include an uncorrected coagulopathy, cardiac,
haemodynamic or rhythm instability, unstable angina or respiratory distress not
attributed to the pleural effusion
 Relative contraindications include lack of patient co-operation, mechanical ventilation,
bullous lung disease and local chest wall infection
 Occasionally, due to frailty or poor overall condition, it may be inappropriate to perform
the procedure as an outpatient and the patient must be admitted.

Procedure
 Most patients will have had an USS and ‘x marks the spot’ performed and a suitable
site for aspiration will have been marked on the skin. This is especially useful if the
fluid is loculated, and should give you a guide as to the volume and depth of fluid. If no
USS has been performed, obtain a lateral decubitus chest x-ray to confirm the
presence of free fluid - pleurocentesis may be performed safely if 10mms of free fluid is
identified on lateral decubitus chest x-ray.
 The position of the effusion should be confirmed by percussion and the side double
checked on the PA CXR.
 Explain the procedure to the patient, verbal consent is satisfactory.
 Position the patient in a chair, leaning forward with the arms on a pillow on a bed or
with the patient sitting backwards on a chair with their arms on a pillow over the back of
the chair.
 Using percussion and vocal resonance locate the upper limit of the effusion and the
area of maximal dullness overlying the known location of the effusion. If an ultrasound
has been used to identify the effusion position the patient in the same way as for the
ultrasound.

CDHB Hospital Palliative Care Service May 2008 Review 2010

 The needle is generally inserted at the mid scapula line unless an alternate site has
been identified on ultrasound - the site of the aspiration should be 1 - 2 intercostal
spaces below the top of the effusion in the mid scapula line.
CAUTION - the liver may be situated at the 9th intercostal space on the right
 Using aseptic technique:
1. Infiltrate with local anaesthestic using 26G needle followed by the 22G needle until-
pleural fluid is aspirated.
2. A 10-20ml syringe is attached to the Insyte catheter - the needle is inserted over
the superior rib margin – avoid the lower border of the upper rib to prevent damage
to the subcostal neurovascular bundle.
3. Gentle suction is applied to the syringe while the cannula is advanced - once fluid
flows back into the syringe the needle should be partially removed (to prevent lung
puncture) and the cannula advanced.
4. The syringe and the needle should be removed, a gloved fingertip applied over the
open cannula and a closed three way stop cock attached to the cannula.
5. The cannula should be securely attached to the chest wall using micropore tape
with a gauze square for padding if necessary. The two TegadermTM dressings are
then used to ‘sandwich’ the catheter to the chest wall.
6. A giving set is pushed firmly into the top of a catheter bag and the free end attached
to the stop cock.
7. The stop cock is opened and fluid should flow into the bag.
8. If fluid does not flow attach a 20-50ml syringe to the free port on the stop cock and
aspirate up to 50mls – this should allow flow to start due to siphoning.

Terminating the procedure

 Aspiration should be stopped when 1000-2000mls has been removed, depending on
the patient's size - removal of larger quantities puts the patient at risk of re-expansion
pulmonary oedema.
 If cough develops, the procedure should be suspended temporarily until coughing
resolves. If coughing continues or the patient feels new chest discomfort (possibly
indicating mediastinal shift) the procedure should also be abandoned.
 To stop draining, close the stop cock and remove the cannula on expiration to reduce
the risk of pneumothorax - an air-tight dressing or plaster is then applied. (The nurses
routinely do this).
 Patients routinely have a CXR post-removal of the catheter, which should be reviewed
prior to the patient leaving the hospital.
 If concerned, examine the patient for the possibility of pneumothorax by checking that
the trachea is central and that there is good air entry particularly at the apices - if air
entered the pleural space during the procedure or if there is any doubt obtain an
urgent CXR to check for pneumothorax.
 Haemorrhage should not be a problem provided the needle is not inserted near the
lower rib margin where the neurovascular bundle is situated.
 Air embolism is rare but catastrophic complication.

Specimen collection
 Diagnostic specimens may be sent to the laboratory. It may be useful to send a large
volume of fluid (up to 500mls) particularly attempting to prove malignancy. Canterbury
Health Laboratories should be consulted for the specifics of sample collection in
individual cases.

CDHB Hospital Palliative Care Service May 2008 Review 2010

Post-care
 Pulse and BP should be performed if the procedure is stopped due to adverse effects
or if the patient feels unwell in any way.
 Puncture site bleeding can be a complication - haemostasis is usually achieved when
pressure is applied to the area.
 A significant pneumothorax will need expert management by the Respiratory
Physicians.
 The patient should remain in the department for 30 minutes after the procedure is
completed and must not drive him/herself home.
 The patient must be advised who to contact during and after working hours should
complications develop.

Documentation
 The amount of fluid drained should be recorded in the Oncology Notes as well as in the
Hospital Clinical Records (if performed in the DSU). Note also whether problems or
complications were encountered, including relevant recordings.

CDHB Hospital Palliative Care Service May 2008 Review 2010