胸腔穿刺术（Thoracic puncture）.docx

胸腔穿刺术（Thoracic puncture）.docx

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胸腔穿刺术（Thoracicpuncture）

Pleuralcavitypuncture（thoracentesis）,referredtoaspleurocentesis,referstothepleuraleffusion（orpneumothorax）patientsfordiagnosisandtreatmentofdiseasesbyathoracicpunctureeffusionorgasextractiontechnologyof.

Table1mainfunctionofpleuralcavitypuncture

2indications

3contraindications

4preoperativepreparation

5operationsteps

Bodyposition,selectionofpuncturepoints

Operationprocedure

6postoperativetreatment

7mattersneedingattention

8complicationsandmanagementprinciples

Pneumothorax

?

bleeding,hemothorax?

Diaphragmaticinjury,liverandotherabdominalorganinjury

Pleuralreaction

Intrathoracicinfection

Multiplepulmonaryedema

9safetyguidelinesforthoracicpuncture

10waystoimprove

Pleuralcavitypuncturenegativepressuredrainagedevice

Applicationoftrocarinpleuralpuncture

Applicationofdrainagetubeinpleuralpuncture

Applicationofcentralvenouscatheter

1.,themainroleofpleuralpuncture

Takepleuraleffusionforgeneralcharacterexamination,chemicalexamination,microscopemonitoringandbacteriologicalexamination,clearthenatureoftheeffusion,andfindthecauseoftheeffusion;

Extractingtheeffusionandaccumulationofgasinthepleuralcavity,reducingthepressureoftheliquidandgasonthelungtissue,relievingthelungtissueandrelievingthedyspneaofthepatient;

Aspirationofpleuraleffusion,pleurallavage,treatmentofempyema;

Intrapleuraladministrationofintrapleuralantibioticsoranticancerdrugs.

2indications

（1）diagnosis:

pleuraleffusionofunknownorigincanbeusedasdiagnosticpuncture,chestwatersmear,culture,cytologyandbiochemistryexaminationtoclarifythecauseofthediseaseandtocheckthelungcondition.

（2）,treatment:

producedbyliquidpumping,pumpinggasorchestdecompressioninthetreatmentofunilateralorbilateralpleuraleffusionandpneumatosisofoppression,breathingdifficultiesandothersymptoms;totheintrapleuralinjectionofdrugs（antineoplasticdrugsorpromotepleuraladhesiondrugs）.

3contraindications

（1）weakconstitution,severeillness,difficulttoendurepuncture.

（2）allergictoanesthetics.

（3）coagulationdysfunction,severebleedingtendency,patientsshouldnotpuncturebeforecorrection.

（4）mentallyillorilladvised.

（5）suspectedpleuralechinococcosispatients,puncturecancauseinfectionspread,notpuncture.

（6）infectionnearornearthepuncturesite.

4preoperativepreparation

（1）understandingandfamiliaritywiththepatient，scondition.

（2）talkwiththepatient'sfamilymembers,explainthepurposeoftheexamination,thegeneralprocess,thepossiblecomplications,etc.,andsign.

（3）apparatuspreparation:

chestpuncturebag,asepticchestdrainagetubeanddrainagebottle,skindisinfectant,anaesthetic,sterilecottonball,gloves,holetowel,syringe,gauzeandadhesiveplaster.

5operationsteps

（1）posture

Thepatientwassittingforthechair,twoforearmplacedontheback,foreheaddowntotheforearm.Patientswhocannotgetupareadvisedtositinhalfpositionwiththeirforearmsheldintheocciput.

（2）selectthepuncturepoint

Choseninthechestpercussionoftherealsoundofthemostobviouspartsofpleuralfluidmoregeneraloftentakethescapularlineortheposterioraxillarylineofthe7-8intercostal;sometimeschoosethe6-7intercostalaxillarymidlineoraxillaryfifthintercostalpuncture.EncapsulatedeffusioncanbedeterminedbyX-rayoru11rasonography.Thepuncturepointsaremarkedontheskinwithaswab（LongDanzi）swaborothermarkerpen.

（3）operationprocedure

Aroutinedisinfectionofskin:

topuncturepointasthecenterfordisinfection,diameter15cmorso,twotimes.

Bopenthedisposablepuncturebagforthorax,wearingsterilegloves,aholetowelcoveringthedisinfection,checkthethoracentesispackagegoods,payattentiontothoracicpunctureneedleandliquidsyringeconnectedtocheckwhetherunobstructed,andcheckforleaks.

Cassistantassistcheckandopen2%lidocaineampoule,patientswith5ml,2%lidocaine2-3mlinjectionsyringeinthepuncturesite,fromtheskintotheparietalpleurabylocalinfiltrationanesthesia.Ifthepuncturepointisthescapularlineortheaxillaryline,theintercostalcavityenterstheanesthesianeedlealongtheupperedgeofthelowerrib,suchasthepuncturepoint,theaxillarymidlineorthefrontofthearmpit,theneedleisinsertedbetweenthetworibs.

Dthoracicpunctureneedleandliquidsyringeconnected,andclosetheswitchbetweenthetwotoensuretightclosenotleak.

Patientswithonehandindexfingerandmiddlefingerfixedpuncturetheskin,theotherhandpunctureneedlepiercingslowlyalongtheanesthesianeedle,whentheresistancesuddensenseofloss,turnontheswitchtothechestwithpumpingliquid.Theassistantusesahemostaticforceps（orachestclamp）toassistthefixationofthepunctureneedletopreventpiercingdeepintothelungtissue.Asyringefull,turnofftheswitch（somethoracicpuncturebagdrainagewithasyringeforfront-enddesign,theone-wayvalvecannotclosetheswitch,dependingonthespecificcircumstances）todraintheliquidinthedrainagebag,countingpumpingvolume.

Edrawthepunctureneedleattheendofthedrainage,sterilizelocally,coverthesterilegauze,pressitalittlewhile,andthenfixitwithadhesivetape.

6postoperativetreatment

1.patientswereaskedtolieinsupinepositionorhalfrestforhalfanhour.Bloodpressurewasmeasuredandnochangesintheconditionwereobserved.

2.fillouttheexaminationformandsendthesampleaccordingtotheclinicalneed.

3.cleaninginstrumentsandoperatingsites.

4.doapuncturerecord.

7mattersneedingattention

（1）beforeoperation,thepatientshouldexplainthepurposeofthepuncture,dispelthemisgivings,andsigntheinformedconsent.Forpatientswithmentalstress,diazepamlOmgorcodeine0.03gshouldbegivenhalfanhourbeforetheoperationtostopthepaininthetown.

（2）.Patientsshouldbecloselyobservedthereactionoperation,suchaspatientswithdizziness,pale,sweating,palpitation,chestpressureorpain,syncopeorpleuralallergy;continuouscough,shortnessofbreath,coughphlegmbubblephenomenon,immediatelystoppumpingliquid,and0.1%0.3~0.5mlsubcutaneousinjectionofadrenaline.Orothersymptomatictreatment.

（3）apumpshouldnotbetoomuchortoofast.Diagnosticpumping,50-100mlcan.Forthefirsttime,lessthan600ml,andnotmorethan1000mlafterdecompression.Ifforempyema,eachtimeasfaraspossibleexhausted,suspectedpurulentinfection,theassistantusesteriletesttubetotakespecimens,smear,Gramstaining,microscopy,bacterialcultureanddrugsensitivitytest.Examinationoftumorcellsrequiresatleast100mlandshouldbesubmittedimmediatelytopreventcellautolysis.

（4）strictasepticoperation,theoperationshouldalwaysmaintainthepleuralnegativepressure,topreventairintothechest.

（5）punctureshouldbeavoidedunderninthintercostalspace,soasnottopenetratethediaphragmanddamagetheabdominalorgans.

（6）measurethevitalsignsbeforeandaftertheoperation,andaskthepatienttoliedownfor30minutesaftertheoperation.

（7）formalignantpleuraleffusion,itcanbeinjectedwithantineoplasticagentsorsclerosingagentstoinducechemicalpleurisy,whichpromotestheadhesionoftheviscerallayertotheparietalpleura,closesthechestcavity,andpreventsthepleuralfluidfromaccumulatingagain.Specificoperations:

afterpumping500-1200ml,thedrugs（suchasminocycline,500mg）plusphysiologicalsaline20-30dilutedintotheinjection.Afterthemedicineispushedintothechest,thenthechestfluidispushedinandrepeated2-3times.Thepatientisinstructedtostayinbedfor2-4hours,andthebodypositionisconstantlychangedsothatthemedicinecanbeevenlycoatedinthechestcavity.Iftheinjectionofdrugsisstrongenoughtocausepaininthechest,itshouldbegivenapainkillerorpethidinebeforethedrug.

8complicationsandmanagementprinciples

（1）pneumothorax;

Theincidenceofpneumothoraxwas3%to20%duringthoracicpuncture.Thereasonforagasfromtheoutsideintothejoint,suchasleakage,replacementoftheneedleorimproperuseofthreewaystopcock.Thissituationisgenerallynottreated,andtheprognosisisgood.Theotheristhedestructionofthevisceralpleuraandlungsduringthepuncture.Asymptomaticpatientsshouldbecloselyobservedandfollowedup.Ifyouhavesymptoms,youneedcloseddrainageofthethoraciccavity.

（2）hemorrhage,hemothorax

Punctureneedlepuncturecancausebleedinginthelung,chestcavityorchestwall.Asmallamountofbleedingismorecommoninthesubcutaneoushemorrhageofthechestwall,usuallywithouttreatment.Iftheintercostalarteryisdamaged,itcancausealotofbleedingandformthepleuralcavityandaccumulateblood.Itisnecessarytostopbleedingimmediatelyanddrawoutthebloodinthepleuralcavity.Lunginjurycancausehemoptysis,asmallamountofhemoptysiscanbestopped,themoreseverecasesbyroutinetreatmentofhemoptysis.

（3）injuryofdiaphragm,liverandotherabdominalorgans

Thepuncturesiteistoolow,cancausediaphragmaticinjury,liverandotherabdominalorgandamage.

（4）pleuralreaction

Somepatientssufferedfromdizziness,pallor,sweating,palpitation,chestcompressionorpain,faintingandothersymptomsduringthepuncture.Theywerecalledpleuralreactions.Itismorecommoninpatientswithmentalstress,whichisduetotheenhancementofvasovagalreflex.

Atthispointshouldstoppuncture,askthepatientsupine,oxygeninhalation,ifnecess