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Inferior mediastinum, Study notes of Animal Anatomy and Physiology

Rajiv Gandhi University of Health SciencesAnimal Anatomy and Physiology

Part of thorax It has many contents like oesophagus,thoracic duct, sympathetic chain , azygos,hemoazyhos,accessory hemiazygos vein.

Typology: Study notes

2018/2019

Uploaded on 02/15/2019

Supriya1112
Supriya1112 🇮🇳

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bg1
STANDARDIZED
PROCEDURE
THORACENTESIS
(Adult)
1
These procedures are intended to describe procedures performed by Nurse Practitioners and/or Certified
Nurse Midwives (depending on the clinical privileges granted to the individual practitioner) at UC San Diego
Health.
I. Definition
A thoracentesis is a surgical puncture of the chest wall to aspirate fluid or air from the pleural
cavity. A pleural effusion is an abnormal accumulation of fluid in the pleural space.
II. Background Information
A. Setting:
The setting (inpatient vs outpatient) and population (adults vs pediatrics) for the Advanced
Health Practitioner (AHP) is determined by the approval of the privileges requested on the
AHP Privilege Request Form. If the procedure is being done on a Pediatric patient, make
sure Child Life Services is involved and use age appropriate language and age appropriate
developmental needs with care of children, as appropriate to the situation.
B. Supervision:
The necessity of the procedure will be determined by the AHP in verbal collaboration with
the attending physician or his/her designee. Direct supervision will not be necessary once
competency is determined, as provided for in this procedure. At that time, general or
indirect supervision is acceptable.
Designee is defined as another attending physician who works directly with the supervising
physician and is authorized to supervise the AHP.
The AHP will notify the physician immediately upon being involved in any emergency or
resuscitative events or under the following circumstances:
1. Patient decompensation or intolerance to the procedure
2. Bleeding that is not resolved
3. Outcome of the procedure other than expected
C. Indications: To determine the cause of pleural effusion and to remove pleural fluid
therapeutically in the event of respiratory distress.
D. Precautions/Contraindications:
1. Thrombocytopenia, platelets < 50,000
2. Clotting abnormalities (Prothrombin time (PT), partial thromboplastin time prolongation
>1.5 times normal), or anticoagulation therapy
3. Severe cough or hiccups (uncontrolled)
III. Materials
1. Sterile gloves,
2. Prepared thoracentesis tray or:
a. Stopcock
b. Blood transfer set
c. 18-20 gauge 2” angiocatheter
pf3
pf4
pf5

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THORACENTESIS (Adult)

These procedures are intended to describe procedures performed by Nurse Practitioners and/or Certified Nurse Midwives (depending on the clinical privileges granted to the individual practitioner) at UC San Diego

Health.

I. Definition A thoracentesis is a surgical puncture of the chest wall to aspirate fluid or air from the pleural cavity. A pleural effusion is an abnormal accumulation of fluid in the pleural space.

II. Background Information A. Setting: The setting (inpatient vs outpatient) and population (adults vs pediatrics) for the Advanced Health Practitioner (AHP) is determined by the approval of the privileges requested on the AHP Privilege Request Form. If the procedure is being done on a Pediatric patient, make sure Child Life Services is involved and use age appropriate language and age appropriate developmental needs with care of children, as appropriate to the situation. B. Supervision: The necessity of the procedure will be determined by the AHP in verbal collaboration with the attending physician or his/her designee. Direct supervision will not be necessary once competency is determined, as provided for in this procedure. At that time, general or indirect supervision is acceptable. Designee is defined as another attending physician who works directly with the supervising physician and is authorized to supervise the AHP.

The AHP will notify the physician immediately upon being involved in any emergency or resuscitative events or under the following circumstances:

  1. Patient decompensation or intolerance to the procedure
  2. Bleeding that is not resolved
  3. Outcome of the procedure other than expected

C. Indications: To determine the cause of pleural effusion and to remove pleural fluid therapeutically in the event of respiratory distress. D. Precautions/Contraindications:

  1. Thrombocytopenia, platelets < 50,
  2. Clotting abnormalities (Prothrombin time (PT), partial thromboplastin time prolongation

    1.5 times normal), or anticoagulation therapy

  3. Severe cough or hiccups (uncontrolled)

III. Materials

  1. Sterile gloves,
  2. Prepared thoracentesis tray or: a. Stopcock b. Blood transfer set c. 18-20 gauge 2” angiocatheter

THORACENTESIS (Adult)

d. 4X4 gauze pads, 5 ml syringe with 25- 27 gauge 55//8” needle & 22 gauge needle

  1. 1% lidocaine
  2. Chlorhexadine solution
  3. Hemostat

THORACENTESIS (Adult)

  • Unilateral pulmonary edema
  • Laceration of intra-abdominal viscera (puncture of liver or spleen).
  • Subcutaneous emphysema
  • Air embolism
  • Pulmonary laceration

b. Benefits

  • Yield information which may be lifesaving or significantly alter treatment
  • Relief of respiratory distress.
  1. Obtain consent from the patient or appropriate legal designee.
  2. Check platelet count and/or presence of coagulopathy. Consult with attending physician if platelet count is < 50,000, or there is known coagulopathy as to whether platelet transfusion or other intervention is needed prior to thoracentesis.
  3. The patient does not need to restrict food or fluids.
  4. Explain that he/she will receive a local anesthetic to minimize pain during the procedure.
  5. Check patient history for hypersensitivity to the local anesthetic, and Chlorhexadine.

C. Procedure:

  1. Position patient in the sitting position with arms and head resting supported on a bedside adjustable table. If unable to sit, the patient should lie at the edge of the bed on the affected side with the ipsilateral arm over the head and the midaxillary line accessible for the insertion of the needle. Elevating the head of the bed to 30 degrees may help.
  2. The usual site for insertion of the thoracentesis needle is the posteriolateral aspect of the back over the diaphragm, but under the fluid level. Confirm site by counting the ribs based on chest x-ray and percussing out the fluid level. Mark the top of the dullness by washable ink mark or indenting the skin.
  3. Select the thoracentesis site in an interspace below the point of dullness to percussion in the midposterior line (posterior insertion) or midaxillary line (lateral insertion).
  4. Sterile technique should be used including gloves, Chlorhexadine prep and drapes.
  5. Anesthetize the skin over the insertion site with 1% lidocaine using the 5 ml syringe with 25 or 27-gauge needle. Next anesthetize the superior surface of the rib and the pleura. The needle is inserted over the top of rib (superior margin) to avoid the intercostals nerves and blood vessels that run on the underside of the rib (the intercostals nerve and the blood supply are located near the inferior margin). As the needle is inserted, aspirate back on the syringe to check for pleural fluid. Once fluid returns, note the depth of the needle and mark it with a hemostat. This gives an approximate depth for insertion of the angiocatheter or thoracentesis needle. Remove the anesthetizing needle.

THORACENTESIS (Adult)

  1. Use a hemostat to measure the same depth on the thoracentesis needle or angiocath as the first needle. While exerting steady pressure on the patient’s back with the nondominant hand, use a hemostat to measure the 15- to 18- gauge thoracentesis needle to the same depth as the first needle. While exerting steady pressure on the patient’s back with the nondominant hand, insert the needle through the anesthetized area with the thoracentesis needle. Advance the needle until it encounters the superior aspect of the rib. Continue advancing the needle over the top of the rib and through the pleura, maintaining constant gentle suction on the syringe. Make sure you march over the top of the rib to avoid the neurovascular bundle that runs below the rib.
  2. Attach the three way stopcock and tubing, and aspirate the amount needed. Turn the stopcock and evacuate the fluid through the tubing.
  3. Remove the necessary amount of pleural fluid (usually 100 mL for diagnostic studies), but generally not remove more than 1500 mL of fluid at any one time because of increased risk of pleural edema or hypotension. A pneumothorax from needle laceration of the visceral pleura is more likely to occur if an effusion is completely drained.
  4. When draining of fluid is completed, have the patient take a deep breath and hum, and gently remove the needle. This maneuver increases intrathoracic pressure and decreases the chance of pneumothorax. Cover the insertion site with a sterile occlusive dressing.

D. Post Procedure

  1. Obtain an upright portable (expiratory) chest x-ray to evaluate the fluid level and to rule out pneumothorax.
  2. For specimen handling, fill the tubes with the required amount of pleural fluid. Check that each tube is properly labeled by checking two patient identifiers- full name, date of birth and/or medical record number.
  3. Pleural fluid should be sent for appropriate lab tests and may include pH, specific gravity, cell count and differential, protein, LDH, albumin, and glucose, culture and gram stain, acid-fast cultures and smears, fungal cultures and smears, viral culture. If a neoplasm is suspected, send for cytology (generally requires 1 L of fluid in a cytology bottle). Send for amylase if you suspect an effusion is secondary to pancreatitis, and Sudan stain and triglycerides if a chylothorax is suspected.
  4. Provide post-procedural analgesics as needed.

E. Follow-up Instruct patient to call MD on-call or the clinic for any chest pain, increased cough, shortness of breath, or signs/symptoms of infection.

THORACENTESIS (Adult)

AHP will be signed off after demonstrating 100% accuracy in completing the procedure.

  1. Demonstration of continued proficiency shall be monitored through the annual evaluation.
  2. A clinical practice outcomes log is to be submitted with each renewal of credentials. It will include the number of procedures performed per year and any adverse outcomes. If an adverse outcome occurred, a copy of the procedure note will be submitted.

VII. RESPONSIBILITY Please contact the Advanced Practice Council if you need help. The administrative assistant for the Chief Nursing Officer can direct you. Call; 619-543-

VIII. HISTORY OF PROCEDURE Revised by the Committee of Interdisciplinary Practices: 2/26/2014, 9/28/ Reviewed by the Medical Staff Credentials Committee: 3/5/2014, 10/6/ Approved by the Medical Staff Executive Committee: 3/20/2014, 10/7/