Thoracentesis; A Critical Analysis of Urban Legends

Background:

Thoracentesis is a relatively safe procedure. Despite a lack of supporting evidence, common assumptions
regarding safety guidelines include: (1) limit fluid removal to<1.5 L; (2) avoid bilateral procedures; (3) do
not tap patients on positivepressure ventilation (intubated or on BiPAP); and (4) routinely obtain a
postprocedure chest xray. To assess the legitimacy of these assertions, we retrospectively analyzed a
large volume of thoracentesis data generated by our Procedure Center at CedarsSinai Medical Center.

Methods:

Five thousand consecutive thoracenteses performed over an 8year period by a single operator at
CedarsSinai Medical Center were retrospectively analyzed. The primary outcome was the rate of major
or minor procedural complications. Subanalyses were performed based on volume removed (1.5L cutoff),
whether unilateral or bilateral procedures were performed, and whether or not the patient was receiving
positivepressure ventilation (PPV) at the time of the procedure. Last, the frequency of postprocedure
chest xrays was reviewed in relation to complications.

Results:

Table 1 breaks down overall, major and minor complication rates into 5 groupings. Major complications
occurred at a significantly higher rate in the highvolume and PPV groups. On the other hand, bilateral
cases had a significantly lower overall complication rate than did unilateral cases. Table 2 displays the
positive and negative predictive values, sensitivity, and specificity of chest xrays as they relate to
postprocedural complications.

Conclusions:

Some widely held beliefs about safety parameters for thoracentesis do not appear to be supported by the
evidence, whereas other teachings do have statistical validity. Overall complication rales in this series
were lower than previously published rates. Within that context, there were significantly increased risks
when removing high volumes (>1.5 L) and/or tapping patients on positivepressure ventilation.
Surprisingly, patients who underwent bilateral thoracenteses had significantly fewer complications than
did patients who had unilateral procedures. Further, our chest xray data (although not comprehensive)
strongly suggests that routine postprocedure chest xrays are not necessary. Ultimately, the decision
about how much fluid to remove and whether to perform bilateral procedures, tap a patient receiving
PPV, or obtain a chest xray should remain in the purview of the treating physician. These decisions should
be guided by an awareness of the evidence, individualized clinical assessments that take into account each
patient's status (before, during, and after the procedure), and the operator's comfort. The risk of any
procedure should be weighed against the potential clinical benefit so that clinicians can property advise
patients and make informed decisions. Last, the importance of maintaining meticulous procedural data
(both as individual practitioners and as group practices) cannot be overemphasized.

The Safety of Thoracentesis in Patients with Uncorrected Bleeding Risk

Abstract

Background: Thoracentesis is commonly performed to evaluate pleural effusions. Many medications

(warfarin, heparin, clopidogrel) or physiological factors (elevated International Normalized Ratio [INR],
thrombocytopenia, uremia) increase the risk for bleeding. Frequently these medications are withheld or
transfusions are performed to normalize physiological parameters before a procedure. The safety of
performing thoracentesis without correction of these bleeding risks has not been prospectively evaluated.

Methods: This prospective observational cohort study enrolled 312 patients who underwent
thoracentesis. All patients were evaluated for the presence of risk factors for bleeding. Hematocrit levels
were obtained pre- and postprocedure, and the occurrence of postprocedural hemothorax was evaluated.

Measurements and Main Results: Thoracenteses were performed in 312 patients, 42% of whom had a risk
for bleeding. Elevated INR, secondary to liver disease or warfarin, and renal disease were the two most
common etiologies for bleeding risk, although many patients had multiple potential bleeding risks. There
was no significant difference in pre- and postprocedural hematocrit levels in patients with a bleeding risk
when compared with patients with no bleeding risk. No patient developed a hemothorax as a result of
the thoracentesis.

Conclusions: This single-center, observational study suggests that thoracentesis may be safely performed
without prior correction of coagulopathy, thrombocytopenia, or medication-induced bleeding risk. This
may reduce the morbidity associated with transfusions or withholding of medications.

Keywords: pleural effusion; pleural cavity; thoracentesis; coagulopathy

Thoracentesis in advanced cancer patients with severe thrombocytopenia: ultrasound guide improves
safety and reduces bleeding risk.

Background: Patients with severe thrombocytopenia are considered at risk for bleeding during invasive
procedures like thoracentesis. The use of ultrasound (US) significantly reduces the rate of pneumothorax
from thoracentesis, but there is a lack of data on safety and efficacy of US guidance in reducing bleeding
complications in thoracentesis performed on patients with severe thrombocytopenia.
Methods: We retrospectively analyzed the efficacy and safety of thoracentesis in cancer patients with
severe thrombocytopenia. From January 2005 to December 2011, 462 patients underwent thoracentesis.
Procedures were divided into two groups: performed without or with US guidance. All procedures were
evaluated for bleeding complications as defined by the National Institutes of Health Common Terminology
Criteria for Adverse Events.

Results: A total of 436 consecutive evaluable thoracentesis were analyzed. Thoracentesis was performed
with US guidance in 310 cases. Forty-one patients (9.40%) had severe thrombocytopenia. In 32 of these
41 patients thoracentesis was performed under US guidance while in 9 cases the procedure was
performed without US guidance. Three mild hemorrhagic complications (0.69 % of the procedures
performed) were observed and all occurred in group of the 9 (33.33%) patients with severe
thrombocytopenia who underwent thoracentesis without US guidance. No hemorrhagic complications
were recorded in the 427 patients, including the 32 patients with severe thrombocytopenia, in whom
thoracentesis was performed with US guidance.

Conclusions: US guided thoracentesis is a safe and effective approach in cancer patients with severe
thrombocytopenia. Our results indicate that this procedure, when US-guided, can be safety performed
even in patients with platelet count below 30x109/L. This article is protected by copyright. All rights
reserved.

Safe and Effective Bedside Thoracentesis: A Review of the Evidence for Practicing Clinicians.

Background: Physicians often care for patients with pleural effusion, a condition that requires
thoracentesis for evaluation and treatment. We aim to identify the most recent advances related to safe
and effective performance of thoracentesis.

Methods: We performed a narrative review with a systematic search of the literature. Two authors
independently reviewed search results and selected studies based on relevance to thoracentesis;
disagreements were resolved by consensus. Articles were categorized as those related to the pre-, intra-
and postprocedural aspects of thoracentesis.

Results: Sixty relevant studies were identified and included. Pre-procedural topics included methods for
physician training and maintenance of skills, such as simulation with direct observation. Additionally, pre-
procedural topics included the finding that moderate coagulopathies (international normalized ratio less
than 3 or a platelet count greater than 25,000/L) and mechanical ventilation did not increase risk of
postprocedural complications. Intraprocedurally, ultrasound use was associated with lower risk of
pneumothorax, while pleural manometry can identify a nonexpanding lung and may help reduce risk of
re-expansion pulmonary edema. Postprocedurally, studies indicate that routine chest X-ray is
unwarranted, because bedside ultrasound can identify pneumothorax.
Conclusions: While the performance of thoracentesis is not without risk, clinicians can incorporate recent
advances into practice to mitigate patient harm and improve effectiveness. Journal of Hospital Medicine
2017;12:266-276.

Improving the safety of thoracentesis.

Purpose Of Review: Thoracentesis is a common bedside procedure associated with iatrogenic

complications including pneumothorax. Experienced clinicians using optimal procedural techniques
within a supportive system can achieve improvements in safety. However, clinicians have been relatively
slow to adopt these changes. This review examines the available literature regarding procedural safety of
thoracentesis with emphasis on best practice models to reduce iatrogenic complications.

Recent Findings: Recent studies have identified procedure-specific variables that are independently
associated with iatrogenic pneumothorax including inexperienced operators, lack of ultrasound imaging,
and large-volume aspiration of fluid. Development of a best practice model including procedural training
within a focused procedural group that utilizes ultrasound imaging further improves thoracentesis
procedural safety.

Summary: Several procedural modifications have led to improvements in thoracentesis procedural safety
in reducing iatrogenic complications. Herein, we review the known risks associated with thoracentesis and
identify the modifiable and nonmodifiable risk factors. On the basis of recent studies, we make
recommendations and encourage incorporation of 'best practice' techniques for thoracentesis
procedures.

Safety of large-volume thoracentesis.

University of Connecticut School of Medicine

Objective: To assess the risks associated with removal of more than 1 liter of pleural fluid in one setting
without intrapleural pressure monitoring.

Design: Single-center retrospective chart review.

Setting: Medium-sized community-based teaching hospital in Bridgeport, Connecticut.

Methods: We reviewed thoracenteses performed between February 2004 and March 2006, and
documented the rates of hypotension, pneumothorax, bleeding, andre-expansion pulmonaryedema.

Results: A total of 300 thoracenteses performed on 237 patients were analyzed, of which 137 were large
volume (>1 liter) and 163 were small volume (<1 liter). There was no statistically significant increase in
risk of pneumothorax, hypotension, or bleeding with large-volume thoracentesis. One case of
radiographically-identified re-expansion pulmonary edema occurred when 2600 mL of fluid were
removed.

Conclusion: Large-volume thoracentesis is a safe procedure that is comparable in risk to small volume
thoracentesis.

Ultrasound-guided thoracentesis: is it a safer method?

Study Objectives: The objectives of this study are as follows: (1) to determine the incidence of
complications from thoracentesis performed under ultrasound guidance by interventional radiologists in
a tertiary referral teaching hospital; (2) to evaluate the incidence of vasovagal events without the use of
atropine prior to thoracentesis; and (3) to evaluate patient or radiographic factors that may contribute to,
or be predictive of, the development of re-expansion pulmonary edema after ultrasound-guided
thoracentesis.

Design: Prospective descriptive study.

Setting: Saint Thomas Hospital, a tertiary referral teaching hospital in Nashville, TN.

Patients: All patients referred to interventional radiology for diagnostic and/or therapeutic ultrasound-
guided thoracentesis between August 1997 and September 2000.

Results: A total of 941 thoracenteses in 605 patients were performed during the study period. The
following complications were recorded: pain (n = 25; 2.7%), pneumothorax (n = 24; 2.5%), shortness of
breath (n = 9; 1.0%), cough (n = 8; 0.8%), vasovagal reaction (n = 6; 0.6%), bleeding (n = 2; 0.2%),
hematoma (n = 2; 0.2%), and re-expansion pulmonary edema (n = 2; 0.2%). Eight patients with
pneumothorax received tube thoracostomies (0.8%). When > 1,100 mL of fluid were removed, the
incidence of pneumothorax requiring tube thoracostomy and pain was increased (p < 0.05). Fifty-seven
percent of patients with shortness of breath during the procedure were noted to have pneumothorax on
postprocedure radiographs, while 16% of patients with pain were noted to have pneumothorax on
postprocedure radiographs. Vasovagal reactions occurred in 0.6% despite no administration of
prophylactic atropine. Re-expansion pulmonary edema complicated 2 of 373 thoracenteses (0.5%) in
which > 1,000 mL of pleural fluid were removed.

Conclusions: The complication rate with thoracentesis performed by interventional radiologists under
ultrasound guidance is lower than that reported for non-image-guided thoracentesis. Premedication with
atropine is unnecessary given the low incidence of vasovagal reactions. Re-expansion pulmonary edema
is uncommon even when > 1,000 mL of pleural fluid are removed, as long as the procedure is stopped
when symptoms develop.
 Thoracentesis is a procedure used in pleural effusions to drain excess fluid found in the pleural
cavity. Physicians care for patients with pleural effusion, a condition that requires thoracentesis for
evaluation and treatment. Many research were conducted to identify the most recent advances related
to safe and effective performance of thoracentesis and mainly conducted to evaluate complications and
risk of patients in performing this procedure. And nurses are to assists and monitor the condition of our
patients.

BODY

Methods:

Five thousand consecutive thoracenteses performed over an 8year period by a single operator at
CedarsSinai Medical Center were retrospectively analyzed. The primary outcome was the rate of major
or minor procedural complications. Subanalyses were performed based on volume removed (1.5L cutoff),
whether unilateral or bilateral procedures were performed, and whether or not the patient was receiving
positivepressure ventilation (PPV) at the time of the procedure. Last, the frequency of postprocedure
chest xrays was reviewed in relation to complications.

Results:

Table 1 breaks down overall, major and minor complication rates into 5 groupings. Major complications
occurred at a significantly higher rate in the highvolume and PPV groups. On the other hand, bilateral
cases had a significantly lower overall complication rate than did unilateral cases. Table 2 displays the
positive and negative predictive values, sensitivity, and specificity of chest xrays as they relate to
postprocedural complications.

Methods: This prospective observational cohort study enrolled 312 patients who underwent
thoracentesis. All patients were evaluated for the presence of risk factors for bleeding. Hematocrit levels
were obtained pre- and postprocedure, and the occurrence of postprocedural hemothorax was evaluated.

Measurements and Main Results:

Thoracenteses were performed in 312 patients, 42% of whom had a risk for bleeding. Elevated
INR, secondary to liver disease or warfarin, and renal disease were the two most common etiologies for
bleeding risk, although many patients had multiple potential bleeding risks. No patient developed a
hemothorax as a result of the thoracentesis.

Methods: We retrospectively analyzed the efficacy and safety of thoracentesis in cancer patients with
severe thrombocytopenia. From January 2005 to December 2011, 462 patients underwent thoracentesis.
Procedures were divided into two groups: performed without or with US guidance. All procedures were
evaluated for bleeding complications as defined by the National Institutes of Health Common Terminology
Criteria for Adverse Events.

Results: A total of 436 consecutive evaluable thoracentesis were analyzed. Thoracentesis was performed
with US guidance in 310 cases. Forty-one patients (9.40%) had severe thrombocytopenia. In 32 of these
41 patients thoracentesis was performed under US guidance while in 9 cases the procedure was
performed without US guidance. Three mild hemorrhagic complications (0.69 % of the procedures
performed) were observed and all occurred in group of the 9 (33.33%) patients with severe
thrombocytopenia who underwent thoracentesis without US guidance. No hemorrhagic complications
were recorded in the 427 patients, including the 32 patients with severe thrombocytopenia, in whom
thoracentesis was performed with US guidance.

Patients: All patients referred to interventional radiology for diagnostic and/or therapeutic ultrasound-
guided thoracentesis between August 1997 and September 2000.

Results: A total of 941 thoracenteses in 605 patients were performed during the study period. The
following complications were recorded: pain (n = 25; 2.7%), pneumothorax (n = 24; 2.5%), shortness of
breath (n = 9; 1.0%), cough (n = 8; 0.8. When > 1,100 mL of fluid were removed, the incidence of
pneumothorax requiring tube thoracostomy and pain was increased (p < 0.05). Fifty-seven percent of
patients with shortness of breath during the procedure were noted to have pneumothorax on
postprocedure radiographs, while 16% of patients with pain were noted to have pneumothorax on
postprocedure radiographs.

Measurements and results: Experienced clinicians using optimal procedural techniques within a
supportive system can achieve improvements in safety. However, clinicians have been relatively slow to
adopt these changes. This review examines the available literature regarding procedural safety of
thoracentesis with emphasis on best practice models to reduce iatrogenic complications.

One of the study conducted talks about the safety of the procedure, that suggests to limit fluid
removal toavoid bilateral procedures; do not tap patients on positivepressure ventilation and routinely
obtain a postprocedure chest xray. Within that context, there were significantly increased risks when
removing high volumes and/or tapping patients on positivepressure ventilation. Surprisingly, patients
who underwent bilateral thoracentesis had significantly fewer complications than did patients who had
unilateral procedures. Further, the chest xray data strongly suggests that routine postprocedure chest x
rays are not necessary. As an advocate, we should be guided by an awareness of the evidence of this
study, individualized clinical assessments from head to toe that take into account each patient's status
before, during, and after the procedure, and the provide comfort.

Another study was conducted to show the safety of thoracentesis in patients with uncorrected
bleeding risk. Thoracentesis is commonly performed to evaluate pleural effusions. Many medications
(warfarin, heparin, clopidogrel) or physiological factors like elevated International Normalized Ratio [INR],
thrombocytopenia, uremia increase the risk for bleeding. Frequently these medications are withheld or
transfusions are performed to normalize physiological parameters before a procedure. The safety of
Patients were evaluated for the presence of risk factors for bleeding. Hematocrit levels were obtained
pre- and postprocedure, and the occurrence of post procedural hemothorax was evaluated. Based on the
result; There was no significant difference in pre- and postprocedural hematocrit levels in patients with
a bleeding risk when compared with patients with no bleeding risk. No patient developed a hemothorax
as a result of the thoracentesis. This observational study suggests that thoracentesis may be safely
performed without prior correction of coagulopathy, thrombocytopenia, or medication-induced bleeding
risk. This may reduce the morbidity associated with transfusions or withholding of medications and we
should also assist the physician in tis procedure with thorough care to prevent pneumothorax and other
possible complications.

Different studies were conducted but it focused on the performed thoracentesis in advanced
cancer patients with severe thrombocytopenia: ultrasound guide improves safety and reduces bleeding
risk. Patients were evaluated, procedures were divided into two groups: performed without and the other
is with US guidance. Three mild hemorrhagic were observed and all occurred in group of the 9 patients
with severe thrombocytopenia who underwent thoracentesis without US guidance. No hemorrhagic
complications were recorded in patients with severe thrombocytopenia, in whom thoracentesis was
performed with US guidance. This shows that we should be aware of the guidelines in performing
thoracentesis for safety and effectivity approach in cancer patients with severe thrombocytopenia. Our
results indicate that this procedure, when US-guided, can be safely performed even in patients with risk
of severe bleeding. We should also explain to the patient the risk and provide information of the
procedure that they can be able to make decisions appropriately.

Ultrasound-guided thoracentesis was evaluated if it is a safe method to be used in thoracentesis

procedure to determine the incidence of complications from thoracentesis performed under ultrasound
guidance by interventional radiologists in a tertiary referral teaching hospital. There was complications
noted upon performing the procedure this are shortness of breath, pain and pneumothorax but with the
help of interventional radiologists under ultrasound there is lower than that reported for non-image-
guided thoracentesis. As a health care team we should help one another to prevent or lower
complications of our patients.

Research were conducted to improved the safety of thoracentesis especially because it is

performed in bedside. Recent studies have identified procedure that are independently harmful and can
risk for developing pneumothorax including inexperienced operators, lack of ultrasound imaging, and
large-volume aspiration of fluid. This suggests that development of a best practice model including
procedural training within a focused procedural group that utilizes ultrasound imaging further improves
thoracentesis procedural safety and effectivity. On the basis of recent studies, we should make
recommendations and encourage incorporation of 'best practice' techniques for thoracentesis
procedures. And we nurses, we should be aware of the new guidelines in performing procedures and help
in research and extension of our field. We should evaluate the skills, participate in trainings and provide
the best interventions we could give for the recovery of our patients.