Pleural puncture for chest injuries. How is puncture of the pleural cavities performed during hydrothorax? Preparing the patient for the procedure

Puncture of the pleural cavity (otherwise known as pleural puncture) is a highly informative diagnostic and effective therapeutic procedure. Its essence is to pierce the chest tissue up to the pleura, followed by examination of the contents of the pleural cavity and its evacuation (removal).

In our article we will discuss in what cases this procedure is indicated and when, on the contrary, it is not recommended, as well as the puncture technique.

Indications, contraindications

For diagnostic purposes, puncture of the pleural cavity is performed when:

• the presence of inflammatory fluid in it - transudate or exudate;
• accumulation of blood in the pleural cavity - hemothorax;
• accumulation of lymphatic fluid in the pleural cavity – chylothorax;
• the presence of purulent masses in it - empyema;
• presence of air in it – .

To determine whether the bleeding in the pleural cavity has stopped, a Revilois-Gregoire puncture test is performed - the blood obtained from the cavity is observed, and if it forms clots, it means that the bleeding is still ongoing.

This manipulation is indispensable in many branches of medicine:

• pulmonology (for various natures, pleura, and so on);
• rheumatology (for other systemic connective tissue diseases);
• cardiology (with);
• traumatology (for other chest injuries);
• oncology (many malignant neoplasms metastasize to the pleura).

In most cases, a diagnostic puncture is combined with a therapeutic puncture - pathological fluid or air is evacuated from the pleural cavity, washed with an antiseptic or antibiotic solution. This manipulation helps to alleviate the patient’s condition, and often save his life (for example, with tension pneumothorax).

A puncture is not performed if the layers of the pleural cavity are fused to each other, that is, its obliteration occurs.

Is preparation necessary?

No special preparatory measures are required for puncture of the pleural cavity. Before the procedure, the patient undergoes a chest x-ray or ultrasound. This is necessary in order to finally verify the need for manipulation and determine the boundaries of the liquid.

The puncture will be as safe as possible for the patient if he behaves calmly and breathes evenly. That is why if a patient is bothered by a severe cough or experiences intense pain, he will be recommended to take painkillers and/or antitussive medications. This will significantly reduce the likelihood of complications during the procedure.

A pleural puncture is performed in a treatment room or dressing room. If the patient’s condition is serious and he is not recommended to move, a puncture is performed directly in the ward.

Methodology

During the manipulation, the patient is in a sitting position on a chair facing its back, on which he leans with his hands, or facing the table (then he leans on it with his hands). For pneumothorax, the patient can lie down on his healthy side and place his upper arm behind his head.

The puncture area is covered with sterile diapers, and the skin is treated with antiseptic solutions.

It is extremely important to correctly determine the puncture site. So, if there is air in the pleural cavity, the puncture is performed in the 2nd intercostal space along the midclavicular line (if the patient is sitting) or in the 5-6th intercostal space along the middle axillary line (if he is lying down). If the presence of fluid is suspected between the layers of the pleura, the puncture is performed along the posterior axillary or even scapular line at the level of the 7-9th intercostal space. The patient must sit. In cases where such a position is not possible, puncture between these two lines closer to the posterior axillary.

In cases where there is a limited accumulation of fluid in the pleural cavity, the doctor determines the puncture point independently by percussion (where the percussion sound is shortened and the upper boundary of the fluid is located) with mandatory consideration of radiographic data.

Before performing the puncture itself, the tissue in the affected area must be anesthetized. For this, infiltration anesthesia is used - an anesthetic solution is gradually injected into the tissue (usually a 0.5% novocaine solution is used). The doctor puts a rubber tube about 10 cm long on a syringe, a long needle with a diameter of at least 1 mm on it, draws an anesthetic into the syringe, fixes the skin at the site of the future puncture with his left hand, slightly pulling it down along the rib, and with his right hand inserts the needle into the tissue just above the upper edge of the rib. Slowly moving the needle deeper, he presses the piston, sending an anesthetic drug ahead of the needle. This is how it enters the skin, subcutaneous tissue, muscles, intercostal nerves and the parietal pleura. When the needle pierces this leaf and enters its destination - the pleural cavity, the doctor feels a failure, and the patient experiences pain.

It is important to puncture along the upper edge of the rib, since the intercostal vessel and nerve pass along its lower edge, which are extremely undesirable to damage.

When the needle “falls” into the cavity, the doctor pulls the syringe plunger towards himself and observes how the contents of the cavity enter it. At the same time, he can visually assess its character and already at this stage draw certain conclusions in terms of diagnosis.

The next stage is evacuation of the contents. When the syringe is filled with liquid, the tube is pinched (so that air does not enter the pleural cavity), the syringe is disconnected and emptied, then reattached and these steps are repeated until the cavity is completely emptied. If the volume of liquid is large, use an electric suction. There are special disposable kits for pleural puncture.

The liquid is collected in sterile tubes for subsequent examination in a diagnostic laboratory.

When the fluid is evacuated, the pleural cavity is washed with antiseptic solutions and an antibacterial drug is injected there.

At the end of these manipulations, the doctor with a decisive movement of his hand removes the needle, treats the puncture site with an iodine-containing preparation, and seals it with a plaster. After this, the patient is taken on a gurney to the ward, and there he remains in a lying position for another 2-3 hours.

During the entire procedure, a nurse works next to the doctor. She carefully monitors the condition of the subject - monitors the frequency of his breathing and pulse, and measures blood pressure. If unacceptable changes are detected, the nurse informs the doctor about them and the puncture is stopped.

Complications

Pleural puncture is a fairly serious manipulation, during which a number of complications may develop. As a rule, they occur when the doctor does not comply with the rules of asepsis, puncture technique, or in case of improper behavior of the patient during the procedure (for example, sudden movements).

So, possible complications:

• injury to lung tissue (air from the alveoli enters the pleural cavity - pneumothorax develops);
• vascular injury (if the intercostal artery is damaged, blood flows into the same pleural cavity - hemothorax develops);
• injury to the diaphragm with penetration of the puncture needle into the abdominal cavity (this can injure the liver, kidney, intestines, which will lead to internal bleeding or peritonitis);
• and the patient’s loss of consciousness (as a reaction to the anesthetic or to the puncture itself);
• infection of the pleural cavity (if asepsis rules are not followed).

Which doctor should I contact?

Typically, a pulmonologist performs a pleural puncture. However, it is used in the practice of traumatologists, cardiologists, rheumatologists, phthisiatricians and oncologists. A doctor in any of these specialties must be able to perform such a manipulation, taking into account data from an ultrasound of the pleura or chest x-ray.

Conclusion

Pleural puncture is an important diagnostic and therapeutic procedure, the indications for which are the presence of air or pathological fluid between the layers of the pleura - exudate, transudate, purulent masses, blood or lymph. Depending on the clinical case, it is performed as planned or as emergency assistance to the victim.

The liquid obtained during the procedure is collected in sterile tubes and then examined in the laboratory (its cellular composition, the presence of a particular infectious agent, its sensitivity to antibacterial drugs, and so on are determined).

In some cases, during a puncture, complications develop that require stopping the manipulation and providing the patient with emergency care. To avoid them, the doctor should explain to the patient the importance of the procedure, his actions during it, and also strictly adhere to the puncture technique and aseptic rules.

The pleural cavity is located between the layers of the same name. It belongs to the respiratory organs, as it is in direct contact with the lungs. Normally, there is a small amount of fluid there, which ensures the physiological act of breathing. In some cases, pathological contents may accumulate in this cavity. He is taken for research to determine the nature and type of the disease.

Definition of the concept

To better understand this issue, certain concepts should be introduced. A pleural puncture is a procedure that helps remove some of the fluid from the area.. In some cases, it is carried out not only for diagnostic purposes, but also when hydrothorax appears. The latter is defined as the accumulation of pathological fluid in the pleural cavity.

It should be noted that fluid collection in this area is not normal. Often it indicates the presence of a serious illness. So, it can accumulate for several reasons:

1. Pleural neoplasm.
2. Tuberculosis.
3. Edema caused by cardiac dysfunction.

Fluid also accumulates in acute conditions. We are talking about the development of hydrothorax. This is usually manifested by difficulty breathing, disruption of normal chest excursion. You can determine whether a person needs a pleural puncture using ultrasound or radiography. Also, in the case of an acute condition, one clinical picture may be enough. In this case, the skills of percussion and auscultation of the lungs come to the aid of the doctor.

When to resort to puncture

A pleural puncture is performed only in a hospital setting. In rare cases, this may be needed in emergency conditions when acute conditions develop. Main indications:

1. Pleurisy. This condition is accompanied by the development of an inflammatory reaction in the pleural layers. As a result, a certain amount of exudate may be released into the cavity. It is usually represented by inflammatory elements. In this case, a diagnostic puncture is performed.
2. Bleeding in the pleural area. Appears in lung cancer. As a result, the cavity is filled with blood elements, which leads to severe and rapid breathing problems. It is carried out for the purpose of diagnosing and saving a person’s life.
3. Empyema. This pathology is accompanied by an accumulation of pus. May occur for various reasons. Most often, the condition is an infection acquired by hematogenous or other means. It is carried out for the purpose of diagnosing and treating the condition.
4. Transudate for edema. Here we are talking about the failure of the heart. As a result, swelling occurs and fluid leaks into the cavity.

This procedure is also used when hydrothorax occurs. This condition is acute and requires quick and prompt assistance.

How to do it

There is no need to prepare the patient for pleural puncture. In some cases, an ultrasound or other research method is performed. The manipulation itself is carried out in stationary conditions. If the patient is in serious condition, directly next to his room. The basic methodology must be followed. It is important that the sick person feels as relaxed as possible. Take into account:

1. General state.
2. Having a cough or difficulty breathing.
3. Presence of pain.

If necessary, cough suppressants or painkillers may be given. This will significantly reduce the risk of complications during manipulation. Let us consider the technique of performing a puncture in the area of ​​the lungs and pleura.

What you will need

For diagnostic manipulation, a small amount of instrument is required. This includes a needle, syringe, painkillers, adapter, and tube. In some cases, after the procedure, a drainage may be installed, which facilitates the outflow of fluid from the cavity.

The procedure for performing the puncture

Pleural puncture is carried out taking into account its characteristics. The algorithm is a little complicated.

1. The patient should be in a sitting position. At the same time, his arm is moved to the side, bent at the elbow and acts as a support.
2. In this position, a needle measuring about 9 cm is inserted.
3. Initially, puncture of the costophrenic pleural sinus is performed.

The injection site itself is located along the line of the shoulder blade or armpit. In medicine, these conditional boundaries are identified for the successful implementation of a number of manipulations. The needle is inserted into the 7th and 8th intercostal spaces. If the exudate itself has already encysted, then the location of the future puncture is determined by ultrasound or x-ray. Already on the basis of this data they make manipulation.

Step by step

Puncture of the pleural cavity is a procedure that is performed following a general algorithm or technique. It should be noted that when carrying out manipulation there is a certain technique. It includes:

1. Before the injection itself, anesthesia is administered.
2. Then the puncture itself is performed using a certain technique.

Let us consider step by step how this diagnostic procedure is carried out.

Step 1

A certain amount of novocaine is drawn into a separate syringe. It is recommended to use 0.5%. Initially, you should take a two-gram syringe. Fill it completely with anesthetic solution.

Please note that the small piston area makes the first step less painful. This must be taken into account in the case of puncture in children.

Step 2

Next, we outline the required injection site. Insert the needle with a slight movement and at the same time press on the syringe plunger. It should be entered from the top. That is, after selecting the desired intercostal space, the needle is inserted at the upper edge. If you start manipulation from the bottom, there is a risk of damage to the artery. This condition may be complicated by the development of bleeding.

Step 3

When inserting the needle, there is a feeling of some resistance. It is caused by the fascia. Then, as it moves and enters the pleural cavity, a feeling of lightness is formed. The resistance disappears, which indicates that the needle has hit the required part.

Step 4

After this, carefully pull the piston back. At this moment, liquid enters the cavity of the syringe. Already at this stage, the doctor can assess what contents are inside. By appearance it is clear whether it is blood, pus or chylosis.

Step 5

The last stage is the most difficult. It is necessary to replace the needle with a thicker one. To do this, pull out the syringe and re-inject it with another needle. The second one is wider in diameter. A suction is connected to it through an adapter or a drainage is installed. Everything will depend on the reason for the puncture.

Puncture as a treatment

Often, a disease that has led to fluid accumulation can cause a therapeutic puncture. The technology is no different, but it just has its own characteristics. First of all, this applies to the introduction of medications into the cavity. Antibiotics are often used for this purpose. Antiseptics may also be delivered to this area. This contributes to the normalization of the patient’s condition and his speedy recovery.

Puncture and hydrothorax

Puncture of the pleural cavity for hydrothorax follows a similar algorithm. It only differs in the speed of conduction, since this condition threatens the patient’s life. Hydrothorax usually develops quickly. The patient suddenly becomes ill, breathing deteriorates noticeably, inhalation and exhalation become difficult.

In this condition, it is necessary to quickly perform a puncture. For a quick reaction, it is important to remember the main points in technology. These include:

1. The main puncture site is between the 7th and 8th intercostal space.
2. The needle should be inserted closer to the upper edge.

Why is it dangerous?

Such manipulation should be carried out exclusively by professionals. For this reason, it should be taken into account that serious health consequences may develop if certain requirements are not met. Basic Rules:

1. Compliance with simple asepsis and antisepsis.
2. Strict adherence to technique.
3. Improper preparation of the patient. This is about ignoring cough or pain.

The main complications will be associated with these aspects. Let's look at the main ones. These include:

1. Damage to the lung itself. One of the serious complications. In this case, air quickly enters the cavity and pneumothorax occurs. In life, such a situation can only arise in the event of a bruise or an accident.
2. Injury to a blood vessel. Accordingly, bleeding develops in this variant. This species is quite difficult to stop, so it can quickly become life-threatening.
3. Damage to the diaphragm itself. Occurs only in emergency situations. For example, this is low professionalism on the part of the doctor or sudden movements on the part of the patient during a puncture. In this case, the needle enters the abdominal cavity.
4. A sharp drop in blood pressure may be a consequence of an allergy to novocaine. For this reason, before carrying out the manipulation, the presence or absence of intolerance is clarified.
5. Getting infected. Occurs due to the fault of medical personnel. The rules of asepsis were violated. Often such a complication quickly makes itself felt.

Despite a number of serious complications, puncture is one of the important procedures. It is diagnostic and treatment at the same time. Most conditions without such manipulation are not possible to detect, and therefore help the patient.

Pleural puncture is a puncture of the chest wall and membrane covering the lungs (pleura), which is performed for diagnostic or therapeutic purposes.

Indications for puncture of the pleural cavity

The main indication for pleural puncture is the suspicion of the presence of air or fluid (blood, exudate, transudate) in the pleural cavity. This manipulation may be required for the following conditions and diseases: exudative pleurisy; pleural empyema; hemothorax; chylothorax; hydrothorax; pneumothorax (spontaneous or traumatic); pleural tumor.

Preparation for pleural puncture

On the day of the manipulation, other therapeutic and diagnostic measures are canceled, as well as medications (except for vital ones). Physical and neuropsychic stress should also be excluded, and smoking should be prohibited. Before puncture, you should empty your bladder and bowels.

Technique for performing pleural puncture

For pleural puncture, a needle with a blunt bevel is used, hermetically connected by a rubber adapter to a system for pumping out fluid.

The manipulation is carried out with the patient sitting on a chair facing the back. The head and torso should be tilted forward, and the arm should be placed behind the head (to expand the intercostal spaces) or rest on the back of a chair. The puncture site is treated with alcohol and iodine solution. Then local anesthesia is performed - usually with a solution of novocaine.

The location of the puncture depends on its purpose. If it is necessary to remove air (puncture of the pleural cavity for pneumothorax), then the puncture is carried out in the third - fourth intercostal space along the anterior or middle axillary line. In case of fluid removal (puncture of the pleural cavity for hydrothorax), the puncture is made in the sixth - seventh intercostal space along the mid or posterior axillary line. The needle is connected to the syringe using a rubber tube. Pumping out the contents of the pleural cavity is carried out slowly to avoid displacement of the mediastinum.

The puncture site is treated with iodonate and alcohol, after which a sterile napkin is applied and secured with an adhesive plaster. Next, the chest is tightly bandaged with sheets. The material obtained during puncture must be delivered to the laboratory for examination no later than an hour later.

The patient is brought to the ward on a gurney in a supine position. During the day he is provided with bed rest and his general condition is monitored.

Indications for drainage of the pleural cavity may be the removal of air from the pleural cavity or the removal of liquid contents, which include blood, inflammatory exudate or pus. Technique:

The site of insertion of the drainage tube is determined by clinical data. Air predominantly accumulates in the upper part of the chest, liquid - in the lower sections. To remove air, a drainage tube is inserted into the anterior-upper sections of the chest, to remove fluid - into the posterolateral surfaces of the chest above the nipple and in the axillary region;

position the child so that the tube insertion site is accessible. Position on the back with the arm abducted 90 degrees on the affected side;

select the required puncture site. In the anterior position of the tube (pneumothorax), the place of pleural puncture should be located in the 2nd or 3rd intercostal space along the midclavicular line. When the tube is in a posterior position (hydrothorax), the puncture is performed in the 6th or 7th intercostal space along the axillary line;

wear sterile gloves. Wipe the puncture site with povidone-iodine solution and cover it with sterile diapers;

at the puncture site, use a 1% lidocaine solution to perform superficial infiltration of the skin and underlying tissues towards the rib. Make a small incision over the rib located below the intercostal space into which the tube will be inserted;

Insert a curved hemostatic clamp into the skin incision and push the underlying tissues apart towards the rib. Use the tip of the clamp to make a hole in the pleura above the rib. Do not forget that the intercostal nerves, artery and vein are located under the lower part of the rib. This technique creates a subcutaneous channel that serves to seal the hole in the chest wall after the tube is removed;

after perforation of the pleura, air can be heard escaping from the pleural cavity;

insert the tube through the open hemostatic clamp. Make sure that the side holes in the tube are inside the pleural cavity. The appearance of moisture in the tube indicates its correct position;

connect the tube to a vacuum drainage system (for example, Pleig-euac). Create a negative pressure of 5 to 10 cm of water column, possibly by immersing the end of the tube in a container with a sterile solution;

secure the tube with a purse string suture. If necessary, strengthen the edges of the skin incision with sutures.

For a more detailed diagnosis of diseases of internal organs, medicine practices the use of a puncture to take their contents for analysis. In addition, punctures enable doctors to “deliver” medications directly to the diseased organ and, if necessary, remove excess fluid or air from it.

The most common procedure in thoracic surgery is puncture of the pleural cavity, the types and algorithm of which will be discussed in this article. Its essence boils down to a puncture of the chest and pleura in order to carry out diagnostics, establish the characteristics of the course of the disease and ensure the necessary medical procedures.

Performing a pleural puncture is vitally important in cases of disruption of the correct outflow of plasma (the liquid component of blood) from the vessels of the pleura, which causes the accumulation of fluid in the cavity (pleural effusion). Pleural puncture helps doctors determine the cause of the disease and take measures to eliminate its symptoms.

A little anatomy

The serous membrane that lines the lungs and the surface of the chest is called the pleura. In the normal state, between its two sheets there is from one to two milligrams of straw-yellow liquid, which is odorless and viscosity, and is necessary to ensure good sliding of the pleural sheets. During physical activity, the amount of fluid increases tens of times, reaching 20 ml.

At the same time, some diseases can also lead to changes in the composition and increase in the contents of the pleural cavity. Diseases of the cardiovascular system, post-infarction syndrome, cancer, lung diseases, including tuberculosis, and even injuries can cause disruption of the outflow of pleural fluid, which provokes the so-called pleural effusion.

An increase in the volume of fluid in the pleural cavity (effusion), the accumulation of air in it that does not escape due to a mechanical obstruction (pneumothorax), as well as the appearance of blood caused by various types of injuries, tumors or tuberculosis (hemothorax) can lead to respiratory or heart failure. In order to clarify the diagnosis and in cases where the patient’s condition is rapidly deteriorating and there is no time left for a detailed examination to save his life, doctors make the only right decision - performing a pleural puncture.

Indications for manipulation

A pleural puncture can be performed for both diagnostic and therapeutic indications. Firstly, the reason for diagnosis is effusion, an increase in the amount of fluid in the pleural cavity to 3-4 ml, as well as taking a tissue sample for examination if a tumor is suspected.

Symptoms of effusion may include:

1. The appearance of pain when coughing and taking a deep breath.
2. Feeling of fullness.
3. The appearance of shortness of breath.
4. Constant dry reflex cough.
5. Asymmetry of the chest.
6. Changes in percussion sound during tapping in specific areas.
7. Weak breathing and voice tremors.
8. Darkening on an x-ray.
9. Changes in the location of the anatomical space in the middle parts of the chest (mediastinum).

Secondly, pleural puncture is indicated for collecting contents from the cavity for bacteriological and cytological analysis in order to identify and confirm pathologies such as:

1. Congestive effusion.
2. Inflammatory process due to fluid stagnation (inflammatory exudate).
3. Accumulation of air and gases in the pleural cavity (spontaneous or traumatic pneumothorax).
4. Collection of blood (hemothorax).
5. The presence of pus in the pleura (pleural empyema).
6. Purulent melting of lung tissue (lung abscess).
7. Accumulation of non-inflammatory fluid in the pleura (hydrothorax).

In some cases, diagnostic pleural puncture can simultaneously become therapeutic. The therapeutic indication for pleural puncture is the need to carry out a number of therapeutic manipulations, such as:

1. Extraction of contents from the cavity in the form of blood, air, pus, etc.
2. Drainage of a lung abscess found in close proximity to the chest wall.
3. Introduction of antibacterial or antitumor drugs into the pleural cavity directly into the lesion.
4. Lavage (therapeutic bronchoscopy) of the cavity for certain inflammations.

Contraindications for puncture

Despite numerous indications, puncture of the chest wall is not recommended in some cases. However, most of the contraindications are relative. For example, regardless of the high risks for the patient in the case of valvular pneumothorax, pleural puncture is performed to save his life.

The following are the circumstances in which physicians will have to decide whether to perform a thoracentesis on an individual basis:

1. High risks of serious complications during and after puncture.
2. Instability in the patient's condition (myocardial infarction, angina, acute heart failure or hypoxia, arrhythmia).
3. Pathology of blood clotting.
4. Continuous cough.
5. Bullous emphysema.
6. Features in the anatomy of the chest.
7. The presence of fused layers of the pleura with obliteration of the pleural cavity.
8. High degree of obesity.

Technique of pleural puncture

A pleural puncture is performed in a treatment room or operating room. For bedridden patients, doctors can perform a similar procedure directly in the ward. Depending on the specific circumstances, the puncture of the chest wall is performed in a lying or sitting position.

During the manipulation, the following set of tools is used:

1. Tweezers.
2. Clamp.
3. Syringes.
4. Needles for administering anesthetic and drainage.
5. Electric suction.
6. Disposable drainage system.

The algorithm for performing the procedure includes the following steps:

1. Local anesthesia.
2. Treating the future puncture site with an antiseptic.
3. Puncture of the sternum and advancement of the needle deeper as the anesthetic infiltrates the tissue.
4. Replacing the needle with a puncture needle and taking a sample for visual assessment.
5. Replacing the syringe with a disposable system for removing fluid from the pleural cavity.

After treating the manipulation site twice with iodine and then with ethyl alcohol and drying it with a sterile napkin, the patient, who sits leaning forward and leaning on his hands, is given local anesthesia, most often with novocaine.

To avoid pain during puncture, it is recommended to use a small volume syringe with a thin needle. The puncture site chosen in advance is usually located where the thickness of the effusion is greatest: in the 7-8 or 8-9 intercostal space from the scapular to the posterior axillary line. It is established after analyzing tapping data (percussion data), ultrasound results and x-rays of the lungs in two projections.

The doctor inserts a needle under the skin, into the tissue and muscle tissue gradually to achieve infiltration of the puncture site with a solution of novocaine until complete anesthesia. To avoid excessive bleeding due to possible injuries to the nerve and intercostal artery, the puncture needle is inserted in a clearly defined area: along the upper edge of the underlying rib.

Once the needle reaches the pleural cavity, the feeling of elasticity and resistance when inserting the needle into the soft tissue is replaced by a dip into emptiness. Air bubbles or pleural contents in the syringe indicate that the needle has reached the puncture site. Aspirate a small amount of effusion (blood, pus or lymph) with a syringe for visual analysis.

Having determined the nature of the contents, the doctor changes the thin needle in the syringe to a reusable one with a larger diameter. Having connected an electric suction hose to the syringe, he inserts a new needle into the pleural cavity through the previously anesthetized tissue and pumps out its contents.

Another option for the procedure is to use a thick needle for puncturing. This approach subsequently requires replacing the syringe with a special drainage system.

At the end of the procedure, the puncture site is treated with an antiseptic and a sterile bandage or patch is applied. The patient must be under the supervision of a doctor for 24 hours. After the procedure, an X-ray examination is performed.

Features of the procedure for different types of effusion

The volume of fluid in the pleural cavity is determined using ultrasound data, which is performed immediately before the procedure. If there is a small amount of exudate in the pleural cavity, the effusion is removed directly with a syringe, without connecting an electric suction. In such cases, a rubber tube is installed between the syringe and the needle, which the doctor squeezes whenever the syringe with liquid is removed to empty it.

After evacuating liquid effusion from the pleural cavity and measuring its volume, the doctor compares the information received with ultrasound data. To ensure that there are no adverse effects, in particular air entering the pleural cavity, a control x-ray is performed.

Puncture for hydrothorax

If there is a significant volume of fluid and blood in the pleural cavity, the blood is first completely removed. After this, in order to avoid displacement of the mediastinal organs and so as not to provoke cardiovascular failure, liquid effusion is removed in a volume of no more than a liter.

Samples of the material obtained as a result of the procedure are sent for bacteriological and histological examination. If there is evidence indicating the presence of non-inflammatory fluid, in particular hydrothorax, the gradual accumulation of fluid after puncture in patients with congestive heart failure does not require repeated puncture. Such effusion is not life-threatening.

Puncture for hemothorax

This type of procedure is carried out in accordance with the established procedure. However, more research is needed to choose the right treatment for hemothorax (collection of blood). The puncture material is used for the Revilois-Gregoire test, which can be used to determine whether bleeding has stopped or is still ongoing. Its continuation is indicated by the presence of clots in the blood.

Puncture for pneumothorax

This procedure can be performed either sitting or lying down. Depending on the position of the patient during the procedure, the puncture site is selected. If the puncture is performed in a supine position, the patient lies on the healthy side of the body and raises the arm held behind the head. The puncture is performed in the 5th-6th intercostal space along the line of the middle axillary upper part of the chest. If the procedure is performed in a sitting position, the puncture is made in the second intercostal space along the midclavicular line. This type of puncture does not require pain relief.

Puncture for cleansing pathological contents

Large volumes of blood, pus and other effusions in cases of injury and the development of complications after punctures are removed using drainage. To clean the pleural cavity from pathological contents, it is drained according to Bulau. This cleansing method is based on outflow based on the principle of communicating vessels.

Indications for the use of this type of puncture are as follows:

1. Pneumothorax, treatment of which by other methods has not given a positive result.
2. Tension pneumothorax.
3. Purulent inflammation of the pleura as a result of injury.

A similar technique is also known as passive Bulau aspiration. The place for drainage in case of gas accumulation is in the 2-3 intercostal space along the midclavicular line, and for liquid contents - along the posterior axillary line in the 5-6 intercostal space. After treatment with iodine, a 1.5-centimeter incision is made with a scalpel, into which a special instrument for puncture, a trocar, is inserted.

A drainage tube is inserted into the hollow outer part of the instrument, through the hole in which the pathological contents are removed. Instead of a troaker, a clamp and a rubber drainage tube are sometimes used. The drainage system is attached to the skin with silk threads, its peripheral part is lowered into a vessel with furatsilin. A rubber valve at the distal end of the tube prevents air from entering the cavity.

In childhood, the procedure for therapeutic purposes is indicated:

1. 1. For aspiration of liquid or gas components from the pleural cavity in order to facilitate breathing.
   2. With exudative pleurisy and pleural ampyema.
   3. For tumor diseases in the chest.
   4. In case of hemothorax and pneumothorax.

For diagnostic purposes, a puncture is performed to obtain analysis from the pleural cavity.

The procedure is carried out directly in the manipulation rooms. The child should lie on his side (back) or sit on a chair. The puncture site is the 5-6th intercostal space (nipple level) or the deepest point of the effusion. First, local anesthesia is performed with a solution of novocaine (0.25%). A “lemon peel” is made with a thin needle, after which it is changed to a needle with a large lumen, which first pierces the skin and then the subcutaneous base. Having moved the needle to the level of the upper edge of the underlying rib, the surgeon punctures the chest wall and infiltrates the tissue with novocaine. Puncture of the pleura gives the feeling of the needle falling into emptiness.

The pleural cavity is anesthetized with two to three milliliters of novocaine, after which a sample is aspirated from it with a syringe. If there is blood, pus or air in it, the doctor connects the needle to the adapter tube and aspirates the contents of the cavity. The contents are removed from the syringe into a previously prepared container, and the syringe is disconnected from the tube with a special clamp. After evacuating the contents, the empyema cavity is washed with antiseptics. The procedure ends with the introduction of an antibiotic, but only after it has been possible to achieve maximum vacuum in the pleural cavity (“collapse” of the rubber tube).

If the first puncture has a positive effect, the manipulations are repeated until complete recovery. If the result of the procedure is unsuccessful (thick pus or an unsuccessful puncture site), one-time punctures are performed in other places until a positive result is obtained.

In the absence of positive results, passive drainage according to Bulau, or active, is indicated by creating a vacuum when connecting the drainage tube to a water jet or electric suction. Also in modern medicine, microdrainage is increasingly being practiced - the use of a venous polyethylene catheter with a diameter of 0.8-1.0 mm, inserted after removing the needle. Its advantages: elimination of organ injury and the possibility of repeated lavages of the pleural cavity with the introduction of antibiotics.

To protect the child from a state of shock due to the loss of a large volume of fluid, as well as to prevent the development of infection and the formation of a fistula at the site of the canal, special care is required for him. Upon completion of the manipulation, the patient is placed on the punctured side and, in order to facilitate breathing, the upper part of the body is placed in an elevated position. Basic vital signs are monitored, in particular, respiratory function is monitored first every quarter of an hour, then every half hour, and then every 2-4 hours. Also make sure that there is no bleeding.

Laboratory test results

The puncture material is examined for tumor cells and pathogenic microorganisms. It also determines the amount and components of blood.

The accumulation of excess proteins in the pleural cavity indicates the inflammatory nature of the fluid as a result of pneumonia, tuberculosis, pulmonary embolism, lung cancer or diseases of the digestive tract, as well as rheumatoid arthritis or lupus erythematosus.

The cause of insufficient protein content in the effusion can be heart failure and a number of other diseases, including sarcoidosis, myxedema, glomerulonephritis.

Blood cells in the effusion are a consequence of injuries or tumors of the pulmonary artery. The detection of tumor cells indicates the presence of metastases and new malignant formations.

Bacteriological analysis of effusion allows us to identify the causative agents of infectious pleurisy.

Complications of pleural puncture

A puncture of the chest is fraught with a number of serious complications, so it is important to strictly follow the examination technique. Complications include:

1. Fainting due to a sharp drop in blood pressure due to puncture.
2. Pneumothorax caused by a puncture of lung tissue or a violation of the sealing of the puncture system.
3. Accumulation of blood in the pleural cavity (hemothorax) due to injuries to the intercostal artery.
4. Infection in the pleural cavity due to violation of asepsis rules.
5. Injury to internal organs due to incorrect choice of insertion site for the puncture needle.

If the patient's condition worsens sharply, the procedure is interrupted. However, we should not forget that pleural puncture is the only effective method of treating effusion. Therefore, for a safe and high-quality study, appropriate preparation, a comprehensive examination, testing and selection of a qualified specialist are necessary.

Subcutaneous injections

Indications

The need to ensure a rapid therapeutic effect of drugs. Introduction of oil solutions. The volume of the drug is 2–5 ml.

Contraindications

Severe tissue swelling. The introduction of agents that cause necrosis and have a strong irritating effect (calcium chloride, magnesium sulfate, etc.) is prohibited.

Equipment

Sterile table, syringes with a capacity of 2 or 5 ml, needles 4–6 cm long, tweezers, sterile cotton balls, sterile tray, alcohol.

Technique

1 . The injection site is the outer surface of the shoulder or thigh, the subscapular space, the lower part of the axillary region, the abdominal area below the navel (Fig. 1).

Rice. 1. Subcutaneous injection sites.

2 . The injection site is treated twice with sterile cotton balls soaked in alcohol. The cotton ball is placed in a sterile tray or squeezed between the fingers of the left hand. With your left hand, collect the skin and subcutaneous tissue into a triangular fold. The syringe is taken into the right hand. Holding the needle sleeve with your index finger and the piston with your little finger, quickly insert the needle into the base of the skin fold from bottom to top at an angle of 45° to a depth of 1–2 cm (Fig. 2). After puncturing the skin, the syringe is transferred to the left hand. The second and third fingers of the right hand pinch the rim of the cylinder, and the first finger presses on the piston handle, slowly introducing the contents of the syringe. After administering the medicine, the needle is quickly removed. The injection site is wiped with a cotton swab and alcohol.

Rice. 2. Subcutaneous injection technique, from left to right: skin puncture, medication administration.

Complications

Subcutaneous infiltrate. Needle breakage. Anaphylactic shock.

Intramuscular injections

Indications

The need to ensure a rapid therapeutic effect of drugs. The volume of the drug is 5–10 ml.

Contraindications

Severe swelling of the tissues Intolerance to the drug The introduction of drugs that cause necrosis (calcium chloride, etc.) is prohibited.

Equipment

Sterile table, syringes with a capacity of 10 ml, needles 6–8 cm long, tweezers, sterile cotton balls, sterile tray, alcohol.

Technique

1 . The injection site is the gluteal muscle (upper outer quadrant of the buttock), thigh muscles (Fig. 3).

Rice. 3. Sites of intramuscular injections.

2 . The injection site is treated twice with sterile cotton balls soaked in alcohol. The cotton ball is placed in a sterile tray or squeezed between the fingers of the left hand. With your left hand, tighten the skin around the injection site. The syringe is taken in the right hand, directing it perpendicular to the surface of the skin, holding the piston with the second finger, V - the needle coupling. With a quick movement, insert the needle to a depth of 4–6 cm, leaving 1 cm of the needle to the coupling (Fig. 4). The piston is pulled slightly towards itself, making sure that the needle does not fall into the vessel, after which the solution is slowly injected into the tissue. Having finished the injection, remove the needle with a quick movement. At this moment, the skin at the injection site should be lightly pressed with a cotton swab moistened with alcohol.

Rice. 4. Intramuscular injection technique.

Complications

Post-injection abscess. Damage to the nerve, periosteum. Needle breakage. Anaphylactic shock. Embolism.

Intravenous injections

Indications

The need to ensure a rapid therapeutic effect of drugs. The volume of the drug is 10–20 ml or more. The need to administer drugs that, when administered subcutaneously and intramuscularly, cause irritation and tissue necrosis.

Contraindications

Drug intolerance. Introduction of oil solutions and insoluble substances.

Equipment

Sterile table, syringe with a capacity of 10–20 ml, needles with a lumen diameter of 0.5–1 mm, 2 sterile cotton balls, a rubber tourniquet, an oilcloth pad, a sterile gauze bandage, rubber gloves.

Technique

1 . The injection site is the superficial veins of the elbow region, less often - the veins of the forearm and hand.

2 . The patient's arm is in the position of maximum extension at the elbow joint. An oilcloth pad is placed under the elbow. A venous tourniquet is applied to the shoulder.

3 . The skin of the elbow is treated with alcohol twice: the first time more extensively, the second time at the site of the intended venipuncture. Using sterile fingers of the left hand, select a vein and tighten the skin below the site of the intended puncture, slightly moving it downward to fix the vein in one position. The prepared syringe is taken into the right hand (Fig. 5).

Rice. 5. Intravenous injection technique.

4 . A vein can be punctured in two ways.

The 2-stage method is applicable in the case of deep subcutaneous veins and poor detection. The syringe with the needle is held in the right hand with the cut side up parallel to the targeted vein and at an acute angle to the skin. The skin is pierced, with the needle located next to the vein and parallel to it. Then, moving the needle forward, a vein is pierced from the side, and a “failure” is felt. Blood immediately appears in the syringe - evidence that the needle has entered a vein. If blood does not appear, pull the syringe plunger towards you. If after this no blood appears, it means that the needle did not enter the vein. In this case, without removing the needle from the skin, repeat venipuncture is performed. When blood appears from the cannula, the needle is moved forward a few millimeters and fixed in this position.

One-stage venipuncture method. In this case, the skin and vein are pierced at the same time. The acute angle between the needle and the skin at the beginning of the puncture decreases even more during the manipulation, and the needle, once in the vein, moves almost parallel to the skin.

5 . After making sure that the needle is in the vein, remove the venous tourniquet. By pressing the piston with your thumb, the drug is slowly injected. In this case, it is necessary to constantly fix the syringe in one position. After finishing the infusion, quickly remove the needle. The puncture site is pressed with a cotton ball soaked in alcohol, and the patient’s arm is bent at the elbow joint for 3–5 minutes.

Complications

Air embolism. Tissue necrosis. Phlebitis. Thromboembolism. Nerve damage.

Pleural puncture

Indications

Removal of fluid from the pleural cavity for diagnostic and/or therapeutic purposes. Removing air for pneumothorax. Injection of gas to compress the lung (artificial pneumothorax). Introduction of drugs.

Equipment

Long needles (8–10 cm) with a diameter of more than 1 mm with a sharp bevel and cannulas for them, syringes with a capacity of 5 and 20 ml, short thin needles for local anesthesia; elastic rubber tubes connecting to the cannula, hemostatic clamps (2 pcs), a suction apparatus, a solution of iodine and alcohol.

Technique

The puncture is carried out in a special room (manipulation room, dressing room, procedural room). 20–30 minutes before the manipulation, 1 ml of a 2% promedol solution is injected subcutaneously. The upper limit of the effusion is preliminarily determined by percussion and x-ray.

1 . The patient's position is sitting on a chair, facing the back of the chair. If the patient's condition allows, it is necessary to tilt the chest to the “healthy” side. The patient should place the hand on the puncture side on the head or on the opposite shoulder.

2 . Preoperative skin preparation includes treating the skin with iodine and alcohol over an area of ​​20´20 cm.

3 . The puncture site is the VII or VIII intercostal space along the posterior axillary line. The puncture is carried out along the upper edge of the underlying rib.

4 . In the intercostal space selected for puncture, the upper edge of the underlying rib is determined with the fingers of the left hand and local anesthesia of the skin (formation of a “lemon peel”), subcutaneous tissue (Fig. 6, left) and periosteum (Fig. 6, center) is performed exactly above the rib. .

5 . A puncture needle with a rubber tube attached to it, clamped with a hemostatic clamp, is placed perpendicular to the surface of the chest. Before the puncture, the skin above the puncture site is slightly shifted with the left hand to form an “oblique” channel. The needle is inserted into the pleural cavity, piercing the skin, subcutaneous tissue, intercostal muscles and pleura. The moment the needle enters the pleural cavity is determined by the feeling of “failure.”

6 . After the puncture, connect a 20 ml syringe to the rubber tube and remove the clamp. The contents of the pleural cavity are sucked out with a syringe (Fig. 6, right) and the tube is again clamped with a clamp. The contents of the syringe are poured into a sterile tube or vial and sent to the laboratory for testing.

7 . The rubber tube is connected to the suction apparatus and, after removing the clamp, the contents of the pleural cavity begin to be evacuated. In this case, rapid evacuation should not be allowed to prevent rapid displacement of the mediastinum and the development of complications (tachycardia, collapse). To prevent these phenomena, periodically close the tube with a clamp. It is recommended to remove up to 1.5 liters of liquid at once.

8 . After removing the fluid, the necessary drug can be administered into the pleural cavity. It is administered by puncturing a rubber tube near the cannula, after squeezing it with a clamp.

9 . At the end of the manipulation, the puncture needle is removed with a quick movement. The puncture site is treated with iodine and sealed with a sterile adhesive tape.

10 . The patient is taken to the ward on a gurney.

Rice. 6. Pleural puncture, from left to right: local anesthesia of the subcutaneous tissue; injection of local anesthetic into the periosteum; aspiration of fluid from the pleural cavity

Puncture for pneumothorax

1 . The puncture site is the II–III intercostal space along the midclavicular line.

2 . The patient's position is lying on his back.

3 . Skin anesthesia is carried out along the upper edge of the underlying rib.

4 . For this puncture, a disposable system for intravenous infusions is preliminarily prepared. In the system, the tube is cut off immediately after the IV and the end of the tube is lowered into a sterile vial of saline solution.

5 . A needle placed on a syringe is used to puncture the pleural cavity (see method above).

6 . After the pleura is punctured, air begins to flow into the syringe. The syringe is removed, and the needle is immediately connected to the cannula of the prepared system. Air begins to escape through the layer of liquid in the bottle.

7 . After the air flow stops, the needle is disconnected from the system and reconnected to the syringe. The syringe plunger is pulled back, drawing air into it, and the needle is quickly removed from the pleural cavity.

8 . After pleural puncture and removal of fluid or air, it is necessary to perform a control x-ray of the chest organs.