1. INDICATIONS

• Diagnostic: pleural effusion, infection, malignancy

• Therapeutic: dyspnea relief, large effusion, empyema drainage

Do NOT perform if:

• Uncorrected coagulopathy (INR > 3, Plt < 25k)

• Infection over the site

• Severe hemodynamic/ventilation instability

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2. PRE-PROCEDURE CHECKLIST

A. Labs

• ✔ Platelets > 25,000

• ✔ INR ideally < 1.5–2.0 (but can be done up to 3)

• ✔ Type & screen if large volume removal

B. Ultrasound

• Identify fluid pocket

• Mark site (mid–posterior axillary line)

• Confirm:

  • No diaphragm

  • No liver/spleen

  • Depth to fluid collection

C. Equipment

• Sterile thoracentesis kit

• Chlorhexidine

• Lidocaine 1%

• Ultrasound with sterile probe cover

• Vacutainer bottles if diagnostic

• Drainage bag or wall suction (low pressure)

Local Anesthesia (routine)

• Lidocaine 1%: 5–10 mL subcutaneous

• Additional 1–2 mL deeper between ribs (walk the needle down rib superior border)

3. STEP-BY-STEP PROCEDURE

1. Time-out

• Patient identity

• Procedure site

• Indication

2. Sterile prep

• Chlorhexidine

• Drapes

• Sterile gloves

3. Ultrasound-guided site localization

• Choose spot: above rib (superior border) to avoid neurovascular bundle

• Depth typically 1–3 cm

4. Local anesthesia

• 1% lidocaine: wheal → deeper infiltration

• Advance lidocaine needle until pleura is felt

• Aspirate to confirm no vessel

5. Insert the introducer needle

• Aim over the rib, not under

• Enter slowly

• When pleural fluid returns → stop advancing

6. Advance catheter

• Slide catheter over needle

• Remove needle

• Connect catheter to drainage tubing or bottle

7. Drain fluid

• Slow drainage

• Max removal: 1.5 L at a time (to avoid re-expansion pulmonary edema)

• Stop if:

  • Coughing

  • Chest pain

  • Hypoxia

  • Hemodynamic changes

8. Remove catheter

• Ask patient to hum during removal (keeps intrathoracic pressure positive)

• Apply pressure dressing

POST: Send labs if diagnostic:

• Protein

• LDH

• pH

• Glucose

• Cell count

• Culture

• Cytology (usually 50–75 mL

Pearl: 

• Always use ultrasound

• Drain slowly to avoid re-expansion edema

• Use no sedation or light sedation only

• Stop immediately if patient coughs severely or feels chest tightness

• Know platelet and INR thresholds

• Always document volume removed and patient tolerance