CPSS Paracentesis,Thoracentesis,Chest Tube Questions with Verified Answers
Indication for paracentesis - CORRECT ANSWER *new onset ascites*
testing
... [Show More] pre-existing fluid
evaluation of patient with ascites who is deteriorating and/or signs of SBP
therapeutic drainage of recurrent/refractory ascites
Relative contraindications for paracentesis:
_________ and DIC
Overlying skin abnormalities like _______, engorged veins, or __________ - CORRECT ANSWER coagulopathies
cellulitis
abdominal wall hematoma
More relative contraindications for paracentesis:
Distended ____________
________ - CORRECT ANSWER intra-abdominal organs
Surgical scars
________ containers and or __________ cannisters are needed in paracentesis. - CORRECT ANSWER evacuated
suction
You can use IV catheters without retractable needles for paracentesis
*DO NOT use IV catheters with ________ as they cannot be detached.* - CORRECT ANSWER safety mechanisms
_______ needles are designed specifically for paracentesis and thoracentesis. They have plastic catheters over a metal needle and multiple side holes. - CORRECT ANSWER Centesis needles
2 types of paracentesis kits - CORRECT ANSWER 1) quick-tap
2) Saf-T centesis catheter
T/F Paracentesis specific devices have been shown to remove larger volumes of ascites more rapidly and require fewer punctures than IV catheters - CORRECT ANSWER True
When performing paracentesis, use the linea alba as a guideline. Avoid the __________. Lower areas are good because fluid travels down via gravity. - CORRECT ANSWER inferior epigastric arteries
In ascites, _______ and _______ may be enlarged. Hollow organs may be distended. The intestines typically _______. - CORRECT ANSWER spleen and liver
float
If the bowel is adherent to parietal peritoneum, _________ is more common when performing paracentesis - CORRECT ANSWER injury
What are the needle entry sites for paracentesis? - CORRECT ANSWER 1) Midline 2 cm below umbilicus at the linea alba
2) right or left lower quadrant 4-5 cm superior and medial to ASIS (LLQ is usually preferred)
When inserting the needle in the RLQ/LLQ, insert the needle lateral to the _________ to avoid inferior epigastric arteries - CORRECT ANSWER rectus sheath
_________ may be distended especially if patient is taking lactulose - CORRECT ANSWER Cecum
If the paracentesis will be a large volume, ______ and monitor __________ - CORRECT ANSWER start an IV
vitals
Use ___________ to confirm entry site over fluid and not over structures - CORRECT ANSWER bedside ultrasound
Like all anesthesia, use a _____ needle to place initial anesthesia then switch to _____ needle to anesthetize deeper tissue. Alternate _______ and ________ - CORRECT ANSWER 25 gauge
22 gauge
aspirating
injecting
Once you insert the needle and attach the syringe. Rotate the catheter around the needle to break the ________ - CORRECT ANSWER factory seal
When inserting needle during paracentesis, aspirate every ____ or so to check for inadvertent vascular placement or entry into peritoneal cavity.
*DO NOT apply suction to minimize bowel injury and immediately stop advancing the needle if _________ fluid enters syringe.* - CORRECT ANSWER 5mm
peritoneal
Paracentesis Pearls:
Use an ______ or 14-18 guage needle to create entry portal for paracentesis
Use the _______ to reduce ascitic fluid leak - CORRECT ANSWER 11 blade
z-track method
Once fluid is removed, remove the catheter and apply firm, direct pressure for several minutes. Clenase the area and cover insertion site with ______ - CORRECT ANSWER sterile occlusive dressing
Samples of fluid must be submitted.
Albumin, protein goes in the ______ tube
Cell count, differential goes in the _____ tube
Gram stain, cytology goes in the ______ or _______
Aerobic or anaerobic cultures go in the _________ - CORRECT ANSWER red top tube
purple top tube (has EDTA)
syringe or red top tube
blood culture bottles
Monitor patients after ____________ for hypotension, circulatory dysfunction or instability. - CORRECT ANSWER large volume paracentesis > 5 L
Complicated cascade that may occurs after large volume paracentesis > 5 L
Increased plasma catecholamine and renin activity causes hypotension, electrolyte imbalance, hepatorenal syndrome, death
Treat with IV albumin - CORRECT ANSWER post-paracentesis circulatory dysfunction
Most common complication of paracentesis - CORRECT ANSWER persistent ascitic fluid leak
z-track helps to prevent
dermabond, skin affix used to treat
Appearance of ascitic fluid:
Translucent or clear yellow: ________
Cloudy/turbid: _______
Pink/blood tinged: __________
*Grossly bloody: ___________*
Milky chylous: ___________-
Brown: _________ - CORRECT ANSWER normal sterile
infection
mild trauma
*malignancy/trauma*
cirrhosis, lymphoma, thoracic duct injury
hyperbilirubinemia, gall bladder or biliary perforation
What is the serum ascites albumin gradient formula?
SAAG > ________ = portal HTN
if less than this it is another cause - CORRECT ANSWER serum albumin - ascites albumin
> 1.1
Must draw serum albumin the same day as the _________. This doesn't need to be repeated after initial measurement. - CORRECT ANSWER paracentesis
SAAG > 1.1 portal HTN is caused by what conditions? - CORRECT ANSWER cirrhosis
alcoholic hepatitis
cardiac ascites
portal vein thrombosis
budd-chiari
liver mets
SAAG < 1.1 is caused by what conditions? - CORRECT ANSWER peritoneal carcinomatosis
tuberculous peritonitis
pancreatic ascites
biliary ascites
nephrotic syndrome
serositis
What test can be performed if ascites is not caused by portal HTN? - CORRECT ANSWER carcinoembryonic antigen
alkaline phosphatase
amylase
triglycerides
cytology
mycobacterial culture
Carcinoembryonic antigen > _________ suggests perforation of a hollow viscus like colon cancer - CORRECT ANSWER 5 ng/mL
Markedly high levels of amylase suggest ______ or perforation of hollow viscus - CORRECT ANSWER pancreatitis
Total protein ______
LDH greater than the upper limits of normal
Glucose _________
all suggest secondary peritonitis instead of SBP - CORRECT ANSWER > 1 g/dL
< 50 mg/dL
Spontaneous infection of ascitic fluid caused by translocation of intestinal bacteria into peritoneal cavity - CORRECT ANSWER SBP
Ascitic fluid PMN count _________ is indicative of SBP - CORRECT ANSWER 250/ml
Intra-abdominal infection from another source like appendicitis, cholecystitis, or diverticulititis - CORRECT ANSWER secondary peritonitis
Ascitic fluid should be sent for ____ and ______ in all patients with possible infection. - CORRECT ANSWER gram stain
culture
**THORACENTESIS starts here** - CORRECT ANSWER
Thoracentesis may be indicated for ______ or ________ purposes when draining pleural effusions. - CORRECT ANSWER therapeutic or diagnostic
Transudative effusions - CORRECT ANSWER CHF
Cirrhosis
Exudative effusions - CORRECT ANSWER malignancy
infection
inflammation
Relative Contraindications to Thoracentesis:
inability of patient to cooperate
overlying _______
mechanical ventilation
____________
coagulopathies, ________, bleeding disorders - CORRECT ANSWER skin infection
hemodynamic/respiratory instability
thrombocytopenia
Lab Values for thoracentesis:
INR _______
PTT typically ________
Platelets _________
is typically considered low risk - CORRECT ANSWER < 2
< 50 seconds
> 50,000
Upright PA CXR can detect pleural effusions ________ and lateral CXR can detect smaller effusions __________ - CORRECT ANSWER > 200 mL
> 50 mL
Obtain a lateral decubitus if ultrasound is not available. If fluid is approximately ______ thick perform a simple thoracentesis. If it smaller or loculated it must be __________ - CORRECT ANSWER 1 cm
ultrasound guided
Arrow Clark Pleura-Seal Kit
Safe-T centesis catheter drainage tray - CORRECT ANSWER used for thoracentesis
Pleural cavity extends to _______ at posterior CVA. Inferior tip of scapula is at ________. Neurovascular bundles are located along the ______ of the ribs - CORRECT ANSWER 12th rib
7th rib
inferior border
Where is thoracentesis performed? - CORRECT ANSWER posteriorly with patient sitting upright midthoracic line
ONE interspace below level of effusion but *never inferior to 9th rib*
Thoracentesis can be performed via axillary approach *for those who can't sit up.* How is this done? - CORRECT ANSWER mid axillary-supine position
posterior axillary-patient in lateral recumbent position with *effusion side down*
Again NEVER inferior to 9th rib
Do you need informed consent for thoracentesis? - CORRECT ANSWER yep
JCAHO created a method to reduce errors during thoracentesis:
1) verify _______
2) ____________
3) take a time out to verify everything - CORRECT ANSWER patient with 2 identifiers
mark the side of effusion
Percuss the chest for transition of _______ and ______ and perform tactile fremitus for transition between normal and absent to determine the level of effusion - CORRECT ANSWER dullness
tympany
Needle will enter at least ________ below the top of the effusion going over the ________ of the rib to avoid the neurovascular bundles. *Always mark the site before!* - CORRECT ANSWER one interspace
superior border
Can a CXR determine the height of the effusion? - CORRECT ANSWER not reliably...it should not be used
Use ultrasound to identify pleural effusions and entry site. Lung will appear _________ and pleural fluid will appear ______ - CORRECT ANSWER hyperechoic (bright)
hypoechoic/anechoic (dark)
When inserting needle, direct it to come in contact with the superior surface of the rib or _____ then gently _______ it over the surface of the rib - CORRECT ANSWER bone
walk
Needle advancement should be stopped once ________ enters syringe - CORRECT ANSWER pleural fluid
Immediately place a finger over the catheter hub after the needle is removed to prevent _______ - CORRECT ANSWER air from entering pleural cavity
When draining the stopcock is opened otherwise it should be closed immediately. Failure to do so may cause _______ - CORRECT ANSWER pneumothorax
Never remove more than ________ of fluid at a time as you may cause re-expansion pneumonia - CORRECT ANSWER 1500 mL
Time catheter removal with _________ - CORRECT ANSWER exhalation
Traditionally ___________ was always performed after thoracentesis but this may not be necessary and is not mandatory.
When should it be obtained:
1) __________
2) chest pain, dyspnea, or hypoxemia
3) multiple _______ were required
4) patient is critically ill or on ________ - CORRECT ANSWER CXR
apiration of air
needle passes
mechanical ventilation
Rare- may occur after removal of large volumes of fluid
Stretching and distension of pulmonary parenchyma causes pulmonary edema
Dyspnea, tachycardia, and frothy sputum - CORRECT ANSWER re-expansion pulmonary edema
Monitor pleural pressures during thoracocentesis. If ______ terminate the procedure as it may cause re-expansion pulmonary edema - CORRECT ANSWER < -20 mm Hg
Caused by increased hydrostatic pressure in vascular space - CORRECT ANSWER Transudate (CHF, cirrhosis)
Caused by increased capillary permeability or lymphatic obstruction - CORRECT ANSWER Exudate (infection, cancer, pneumonia)
Think "exude" the nasty
Light's Criteria compares pleural fluid protein and LDH and determines if fluid is ______ or not.
Pleural protein to serum protein ratio > .5
Pleural LDH to serum LDH ratio > .6
Pleural fluid > 2/3 the upper limit of normal serum - CORRECT ANSWER exudate
Quick, simple life saving procedure used to relief suspected tension pneumo - CORRECT ANSWER needle thoracostomy
Needle thoracostomy requires subsequent _____ - CORRECT ANSWER tube thoracostomy (chest tube)
Progressive accumulation of air in pleural space, increased ipsilateral pressure and collapse of lung
Contralateral shift of mediastinum - CORRECT ANSWER tension pneumothorax
Respiratory distress
Chest pain
Tachycardia
Hypotension
Diminished or absent lung sounds
Hyperresonance (ipsilateral)
Tracheal shift (contralateral)
Jugular venous distension (increased CVP) - CORRECT ANSWER tension pneumothorax
When is a needle thoracostomy indicated? - CORRECT ANSWER O2 < 92%
Systolic BP < 90
Respiratory Rate < 10/min
Decrease LOC
High risk like mechanical ventilation
Which indications of tension pneumo should have an xray first? - CORRECT ANSWER a patient on mechanical ventilation
What are the contraindications to needle thoracostomy? - CORRECT ANSWER NONE-just be careful on those with coagulopathies
What equipment is needed for needle thoracostomy? - CORRECT ANSWER skin cleansing agent
*14-16 gauge* over the needle catheter (standard IV cath)
10 mL syringe
Catheter selection
Needle must be at least _________ - CORRECT ANSWER 5 cm or 2 in
Where is a needle thoracostomy performed? - CORRECT ANSWER MCL 2nd intercostal space
aka OVER superior surface of 3rd rib
Advantages of midclavicular approach - CORRECT ANSWER air rises to anterior chest
protects lung
easy reach from head of bed
easily monitored
Disadvantages of midclavicular approach - CORRECT ANSWER chest wall thick
subclavian vessels and internal mammary artery at risk
Needle thoracostomy can also be done at the midaxillary line __________ inserting the needle over the superior aspect of the 5th or 6th rib. - CORRECT ANSWER 4th or 5th intercostal space
Midaxillary approach is good for thin chest wall and is farther away from major vessels.
The intercostal space are ______, there's more rib excursion, and increase risk for _________ - CORRECT ANSWER narrow
Obtain written consent
Place patient in supine position
Supplemental O2
Cardiac monitor
2 large bore IVs
Prep for chest tube
Order portable CXR - CORRECT ANSWER prep for needle thoracostomy
Needle is inserted ______ to skin in needle thoracostomy and advanced until a ________. - CORRECT ANSWER perpendicular
rush of air or blood
Tube thoracostomy indications:
Evacuate abnormal accumulation of air or fluid via ________, hemothorax, or ______
Restore normal slight___________ - CORRECT ANSWER pneumothorax
pleural effusion
negative intrapleural pressure
Sudden onset pleuritic chest pain
Dyspnea
Cough
Restlessness/agitation
Impending doom
Hypotension
Elevated CVP and PAOP
symptoms that likely need ___________ - CORRECT ANSWER tube thoracostomy
What are some signs a patient may need tube thoracostomy? - CORRECT ANSWER tachycardia
hypotension
dyspnea
neck vein distension
tracheal deviation
diminished breath sound hyper-resonance
subq emphysema
pulsus paradoxus
*may be totally normal exam*
GOLD standard for diagnosis pneumothorax, pleural effusion, hemothorax - CORRECT ANSWER Thoracic CT
On ultrasound the ____________ sign rules out pneumothorax - CORRECT ANSWER sliding lung sign
Absence of peripheral lung marking
Distinct line indicating edge of collaped lung
Produces significant dyspnea in those with lung disease like COPD - CORRECT ANSWER pneumothorax
What is often mistaken for pneumothorax? - CORRECT ANSWER bullae
skin folds
border of scapula
3 types of pneumothorax - CORRECT ANSWER 1) spontaneous
2) traumatic-open or close
3) tension
NO underlying disease; typically tall thin male - CORRECT ANSWER primary spontaneous pneumo
*these are clinically stable*
Small primary spontaneous pneumo
________
Observe and repeat CXR every 3-6 hours
Discharge if no progression
F/U in _______
Readmit if unreliable f/u - CORRECT ANSWER < 3 cm apex to cupola
12-24 hours
Large primary spontaneous pneumo
________
Possible ________ then observation
Catheter/chest tube with valve or water-seal
May discharge with valve and follow-up ______ if lung re-expanded - CORRECT ANSWER > 3 cm apex to cupola
aspiration
24-48 hours
Underlying disease caused pneumo - CORRECT ANSWER secondary spontaneous pneumo
*clinically stable*
Small stable PTX is hospitalized and observed or chest tube depending on progression.
Large stable PTX is hospitalized and gets chest tube - CORRECT ANSWER ok
An open traumatic pneumothorax may develop into _________ - CORRECT ANSWER tension pneumo
Progressive accumulation of air in pleural space; life threatening
On CXR:
Mediastinal shift to contralateral side, flattened ipsilateral hemidiaphragm - CORRECT ANSWER tension pneumo
Treatment for traumatic pneumo depends on:
_______
age
_______
bilateral pneumo - CORRECT ANSWER stability
size of pneumo
Fluid in chest cavity is seen as a *straight line without meniscus*; may occur after stab wound to chest - CORRECT ANSWER hemopneumothorax (air and blood)
You need to determine if the patient is clinically stable. What vitals indicate that?
RR- ________
HR- ________
O2 sats- ______
Normal BP
Able to speak whole sentence with one breath - CORRECT ANSWER < 24 /min
60-120 bpm
> 90%
In a hemothorax, monitor the amount and rapidity of bleeding. 75% are managed with ____ and ______. Hemothorax > _________ needs early blood replacement - CORRECT ANSWER chest tube
volume replacement
2000 mL
Massive hemothorax (> 1000-1500 mL)
Continued bleeding
___________ of hemothorax
Persistent hemothorax
__________ hemothorax
Persistent or large air leak
Inability to __________
are all indications for chest tube - CORRECT ANSWER increasing size
clotted hemothorax
fully expand lung
*There are NO absolute contraindications to chest tubes*.
Relative contraindications include the following:
multiple _______
_______
scarring
coagulopathy - CORRECT ANSWER pleural adhesions
blebs
Adult chest tube sizes - CORRECT ANSWER 8-42 french
smaller tubes for small pneumo, larger for hemothorax, empyema
Use the __________ chest tube possible when draining a suspected hemothorax. - CORRECT ANSWER largest (minimum 36 french)
2 Standard sites for chest tube insertion - CORRECT ANSWER 1) 2nd intercostal space, midclavicular line
2) 4th or 5th intercostal space midaxillary line
Before inserting the chest tube, hold tube up to chest wall. Estimate the distance from _______ to _______. Ensure ALL _______ are within the pleural space. Mark maximum insertion length with clamp. - CORRECT ANSWER incision to apex
holes
Place the patient on oxygen. Head of the bed should elevated __________ and the ipsilateral arm should be restrained _______ before beginning the chest tube - CORRECT ANSWER 30-60 degrees
overhead
Anesthesia is first performed over the rib at the _______. Then advance needle slowly _______ of that rib while intermittently infiltrating and aspirating until pleura is breeched. - CORRECT ANSWER incision site
over the top
Use a __________ scapel and make a _________ incision 3-5 cm through skin and subcutaneous tissue - CORRECT ANSWER #10
transverse
Once you open the tunnel with the kelly clamp, you must push into the pleural space. What signifies penetration into pleural space? - CORRECT ANSWER rush of air or fluid
If the hole created is too large, ________ will leak and may lead to subcutaneous emphysema. - CORRECT ANSWER air
The finger sweep method can be used to guide the chest tube into the pleural cavity. Do NOT ________ because the hole may be easily lost, especially in an obese patient. - CORRECT ANSWER remove your finger
To insert the chest tube, grasp the tube with the ________. Chest tube should insert with little to no resistance.
Direct the tube _______, _________, and _______.
Insert the tube up to the marker clamp or the last hole clearly intrathoracic. - CORRECT ANSWER clamp
posterior, medial, and superior
The tube must be secured with an initial __________ then wrap the tails around the tube and tie. You may also perform ___________ on either side of the tube - CORRECT ANSWER stay suture
horizontal mattress suture
Apply occlusive dressing to the incision site. Wrap the base of the tube with ____________ dressings and two layers. Second layer is applied at a 90 degree angle to first. - CORRECT ANSWER petroleum impregnated
This device alone is often sufficient to treat pneumothorax. May be used in outpatient setting. - CORRECT ANSWER Heimlich valve
*not for hemothorax*
Chest tubes are attached to drainage systems. They must remain below _____________ (at least 100 cm) - CORRECT ANSWER level of patient
Bubbling in the drainage system indicates an air leak. Clamp the tube off at the insertion site. If the bubbling stops, the leak originates from ___________ the patient. - CORRECT ANSWER inside
A *patient air leak* must be monitored at frequent intervals-every ________. Disconnect suction and observe. Assess and document degree of air leak using a Pleur-evac Air Leak Meter ________ is low and ______ is high - CORRECT ANSWER 4 hours
1
7
If you have a *system air leak*, find the origin by clamping every 8-12 inches, tighten all connections, and tape connections - CORRECT ANSWER ok
Chest tube catheters may become clogged with mucus or blood, flush with ________ every 6-8 hrs if this happens - CORRECT ANSWER sterile saline
Using an "over the wire" technique is more common these days
The guidewire is passed through the needle over the rib into the pleural space then removed and the cathether is left. - CORRECT ANSWER seldinger technique
The needle is advanced in a straight line. _____________ cannot be used. - CORRECT ANSWER tunneling approach
Bleeding
Injury to solid organs/nerves
Subq emphysema
Re-expansion pulmonary edema
are all complications of chest tubes - CORRECT ANSWER ok
To remove chest tube, place patient at ________. Cut sutures and ______ tube. Remove the tube when the patient is either ____________ . Repeat CXR in 6 hours - CORRECT ANSWER 45 degrees
clamp
inhaling or exhaling [Show Less]