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BackTable / VI / Article
How to Prevent Thoracentesis Complications: Pneumothorax, Hemothorax & Re-Expansion Pulmonary Edema
Kaitlin Sheppard • Updated Feb 24, 2025 • 36 hits
Thoracentesis is a cornerstone procedure in the diagnosis and treatment of pleural effusion. However, balancing timely, effective fluid removal with procedural safety remains a clinical challenge, particularly when managing large or complex effusions. .
Drawing on his extensive experience with thoracentesis, interventional radiologist Dr. Paul Lewis shares practical strategies to refine the thoracentesis procedure and minimize complications, focusing on imaging guidance, needle placement, and post-procedure techniques to prevent pneumothorax, hemothorax, and re-expansion pulmonary edema.This article features excerpts from the BackTable Podcast, where clinical experts share practical knowledge to improve patient outcomes.
The BackTable Brief
• Real-time or pre-marked ultrasound guidance reduces complications like pneumothorax by ensuring accurate needle placement.
• Routine chest x-rays post-thoracentesis help identify pneumothorax and provide a baseline for future care.
• Ultrasound guidance reduces pneumothorax rates to less than 1%. Distinguishing ex vacuo pneumothorax from a true complication can avoid unnecessary interventions.
• Staged procedures for bilateral thoracentesis allow for reassessment of symptoms and determine if there is a need for further interventions.
• Fluid removal should be guided by clinical experience and patient tolerance, with initial limits around 1 to 1.5 liters for naive patients and up to 2 liters for experienced cases.
• Patients should be monitored for symptoms such as coughing, chest pain, and dyspnea to determine when to stop drainage.
• Advanced pumps, such as the Laborie Renova, allow for controlled drainage speeds, reducing patient discomfort and improving procedural efficiency.
• The variable-speed pump provides flexibility, enabling slow drainage for sensitive cases and faster removal when clinically appropriate.
Table of Contents
(1) Thoracentesis Puncture Site Selection & Post-Procedural Care
(2) How to Prevent Thoracentesis Complications: Pneumothorax, Hemothorax & Re-Expansion Pulmonary Edema
(3) Bilateral Thoracentesis: Single Session or Staged Approach?
(4) Monitoring for Thoracentesis Complications During Fluid Removal
Thoracentesis Puncture Site Selection & Post-Procedural Care
When selecting the entry point, Dr. Lewis recommends aiming for one intercostal space above the lowest visible fluid pocket on ultrasound to avoid diaphragm interference. Post-procedural care for thoracentesis begins with securing the puncture site to prevent complications. Petroleum gauze, applied directly to the insertion point and covered with sterile gauze, creates a seal that reduces the risk of air entry and infection. A post-procedure chest X-ray is obtained within an hour to assess for pneumothorax and evaluate lung expansion. Observation during this period allows for monitoring of vital signs and any emerging symptoms.
[Dr. Christopher Beck]:
Post-op, how does that look?
[Dr. Paul Lewis]:
In patients, we do get x-rays. As far as, yes, maybe dilemmas or controversies, number one, we go with the petroleum gauze. I do that. Another site in our system just puts a bandaid. There's certainly the spectrum and physician discretion. I drink the juice. I put the petroleum jelly and then the gauze.
[Dr. Christopher Beck]:
Does the petroleum gauze come in the kit?
[Dr. Paul Lewis]:
No, it doesn't. That's the one thing that doesn't come in with the kit. The sonographers, again, they're managing the tube and so they place it. Maybe they don't do it, and they just tell me they do.
[Dr. Christopher Beck]:
I think you like when I check with your sonographers if you're getting as much petroleum gauze, like they probably told Dr. Lewis, "No one else is using this. It doesn't even come in the kit." How about x-ray afterwards?
[Dr. Paul Lewis]:
Yes. In the beginning, I wouldn't do that. Then I had one patient and all it takes is one patient. She presented days later asymptomatic, but with a pneumothorax, and I felt, you know what, we should take the blood pressure, make sure there is no hypertension. We do get that chest x-ray afterwards. For outpatients, it's usually by the time they get that chest x-ray, the final reads in, it's been an hour, so we have that observation time.
[Dr. Christopher Beck]:
Okay. About one hour Obs and then chest x-ray cleared and then go home?
[Dr. Paul Lewis]:
Yes.
[Dr. Christopher Beck]:
To echo, we also get a chest x-ray afterwards. I found it helpful. One to look for a pneumo, there's no doubt about that. Let's just like take complications out of it. It's nice to know what the x-ray will look like once you've evacuated the fluid, because you may see that patient recur, like especially for an in-house patient. It's nice to know, hey, this is what the lung looks like when you've taken out as much fluid as a thoracentesis can take. One thing, not to beat it to death, and I just was thinking about my actual practice. Whenever you're choosing where to drain the fluid on the body, we talked about lateral or medial to lateral. What about high versus low? Do you have any opinions on choosing like the lowest spot possible to get the fluid or just whatever looks like the nicest pocket?
[Dr. Paul Lewis]:
Yes. Thank you for going back to this question. I apologize for overlooking answering this.
[Dr. Christopher Beck]:
You don't have to apologize, Paul. We don't apologize to our audience. We give them what they get.
[Dr. Paul Lewis]:
One is that the fluid collection directs me on where to go. Sometimes it's loculated, anterior, superior, and then we're doing it that way, that location, but most commonly posteriorly or posterolateral. Not as low as I possibly can. Usually one inner space above the lowest inner space I could see it in. The question is, well, if you're draining a pool, you want to drain it from the bottom. When I was listening to my sonographers, they pointed out, when you go so low, it tends to catch on the diaphragm. Remember the posterolateral gutter, it's crescent shape. It comes down to a point. If I'm going really low, I may be running into the diaphragm earlier than I usually would. Now I go one inner space above the lowest inner space that I could see the fluid in.
[Dr. Christopher Beck]:
Yes, I think that's solid. We also do a lot of coaching with our sonographers. What I like to have them do is scan the patient and have like a ballpark of where-- I'll actually pick the spot, but I like to have them give it their best go as far as trying to mark a spot for me. Sometimes I can just put the ultrasound probe right on their spot and say, oh, you found the perfect spot. Something similar, I found the lowest spot where I'm seeing fluid, where you can see the diaphragm and you bounce up one above that. That's usually like the deep end.
One of the other things I'm looking for, and you also mentioned it, but I was going to drill down, like to put a slightly finer point on it. Sometimes, if you just watch it just for a second, you can see lung that flaps in and out of it. Yes. I think that's always good to look for. Also like also trying to scan a little bit up and a little bit down, but like, obviously, at least for me, you want to find that rib, climb over it, but it's also nice to be like pointing down if you have that lung, like that's like flapping in and out, like from a-- it's at the top and then it comes into the screen and goes away. It's always nice to-- Also like for those docs that do it. We do it similar to you, like a lot of times it's a mark and then go in rather than real time. For us, it's probably less than 10% of the time where we can do it real time, but not that I disagree with that. I think there's room for both ways.
[Dr. Paul Lewis]:
One more point as far as where you go. We talked about medial to lateral. Again, we'll also try to go, it's certainly the 7 centimeters, but that posterolateral aspect, that's also where I put my PleurX catheters and any drains. I think about the patient when they leave us with a chest tube, if I have that more posteriorly, that's still running over the soft tissues, the ribs, it may cross the ribs. We don't want that. If I enter that or place that to more laterally, it's coming out the side. Nurses can find it easier. Maybe the bandage is more secure there laterally, but for PleurX catheters, that allows us to track even more anteriorly for it to come out of the skin.
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How to Prevent Thoracentesis Complications: Pneumothorax, Hemothorax & Re-Expansion Pulmonary Edema
Thoracentesis complications include pneumothorax, hemothorax, and re-expansion pulmonary edema. Advances in imaging, particularly the use of ultrasound guidance, have significantly reduced the likelihood of pneumothorax by enhancing accuracy during needle placement. Distinguishing between ex vacuo pneumothorax and a true complication is critical for appropriate post-procedural care. Hemothorax, though uncommon, can be avoided by utilizing smaller needle sizes and lateral entry techniques. Similarly, re-expansion pulmonary edema—an infrequent but serious complication—can be addressed with controlled fluid removal and drainage speeds.
[Dr. Christopher Beck]:
Complications. The big ones that I have listed to talk about and maybe there's some other ones, but pneumothorax, hemothorax, and re-expansion edema. You want to start with pneumo, you said you've had it once in the course of a little under 1,000. Is that too bad?
[Dr. Paul Lewis]:
Yes. It was asymptomatic. It does happen. We do talk about it. Statistically, it's less than 1%. I had the one of the thousand that I'm doing. Statistically, it's safe to come to UPMC East. Really, prevention using the ultrasound, far and beyond, as seen in the literature. Once we introduced using image guidance, the incidence went from about 30% down to 0 to 1%. Thankfully, it's a very rare occasion that we have a pneumothorax. Most commonly, it's an ex vacuo, pleural effusion, which you can't do much about. The patient does still have relief. I think that comes back to the benefits of having a thoracentesis. As far as from a more basic science standpoint, a lot of times we'll look at it and say, well, it's increasing the air fluid exchange. It increases the functional tissue and interface for air exchange. It's also, we have to consider the mechanics and using the length tension relation. I'm going to get real nerdy here.
[Dr. Christopher Beck]:
Yes, let's do it, man. This is what this podcast is about.
[Dr. Paul Lewis]:
A length-tension relationship of the sarcomere. If you think about it, you have a pleural fusion. It's stretching out the diaphragm there. It doesn't have that myosin acting crossover. It's being stretched out, so it can't contract, and they can't pull a lot of air in on either side. Once we take that fluid out, we restore that tension-length relationship. There's some posit that's greater benefit than your air exchange area with the thoracentesis. I think the ex-vacuo patients really hit home that argument or a great point in that. Because look, we took out the fluid, that lung didn't re-expand. We didn't change that surface area of gas interchange. The patient has less dyspnea. They feel more comfortable. That has to lead to the mechanical response to removing that fluid. Then it didn't remove that. As far as complications in thoracentesis, specifically pneumothorax, it thankfully is a rarity. We do watch patients and treat them clinically because of the ex-vacuo is far beyond the most common cause or reason for the pneumothorax.
[Dr. Christopher Beck]:
How do you tell the difference between a pneumo and a trapped lung or ex-vacuo pneumothorax, like on chest x-ray?
[Dr. Paul Lewis]:
They're looking at, and again, when we talk about doing our thoracentesis, the beginning should start with the end. We have a chest x-ray to compare to before that we do the procedure. If that lung, what's aerated, is exactly the same as what it is post procedure, that really speaks to, okay, that's trapped lung or ex-vacuo. It's surprisingly so identical. I don't know if you have that same experience, but it's the exact same imprint as far as radiographically, plus and then minus the fluid with the trapped lung or ex-vacuo. The patient, again, they're clinically better from beforehand.
[Dr. Christopher Beck]:
Yes, to put a finer point on it, maybe unnecessarily. I know exactly what you're talking about. I was actually smiling, as you were describing. You have your pre-procedure x-ray, and the fluid's tracking from inferior around the lateral surface of the lung and on the top. Then whenever you remove that fluid, it's like the lung is in exactly the same position. It's just now the fluid's subtracted out. You're like, that's an ex-vacuo. We used to have the hardest time with our diagnostic radiologists. They called everything. They're like, that's a pneumo. Then sometimes, they would say, maybe ex-vacuo pneumothorax.
I hate to have like complication deniability or whatever, but I was like, you know what? I was jumping into like 2-liter pleural effusion. I think that's pretty safe to say that needle position was safe. It's more likely ex-vacuo. It's something to think about. I don't want to dismiss it, but by far and away, like if you have a pneumo, it's probably ex-vacuo. Certainly, I think that's also what it pays to look at your own x-ray afterwards. You can't just go off the read from the diagnostic team.
[Dr. Paul Lewis]:
Yes, absolutely. Say you're in a similar a community setting, you're doing diagnostic interpretation too. You could pick up that chest x-ray.
[Dr. Christopher Beck]:
No doubt.
[Dr. Paul Lewis]:
That said, I do like to have that objective feedback and evaluation or interpretation. Ultimately, a clinical presentation over a radiographic finding. We may keep the patient a little bit longer, get serial x-ray, as far as do we need to treat and keep the patient, how are they safe to go home with someone with them overnight?
[Dr. Christopher Beck]:
Right. Totally agree. Treat the patient, not the pictures. Here's a publication I'm more interested in, hemothorax. Bleeding after thoracentesis. Can you talk about personal experience? Never?
[Dr. Paul Lewis]:
I don't have any. Never.
[Dr. Christopher Beck]:
Oh, man. I'll tell you what, UPMC really is the safest place to have a thora.
[Dr. Paul Lewis]:
Sorry. Had to knock on the wood to make sure that doesn't occur. Really looking across all the literature and what we've experienced in the evolution of guidelines and how much more liberal they are. INR of two, and you said with the SIR guidelines.
[Dr. Christopher Beck]:
INR of three.
[Dr. Paul Lewis]:
Three.
[Dr. Christopher Beck]:
Platelets greater than 20K.
[Dr. Paul Lewis]:
Yes. We necessarily don't need to get the pre-procedure labs. I think it really speaks to just where you do it and how you do it. Minimizing the needle size and where you place it. Again, right over the rib and to that posterolateral aspect of the chest, the anterior, where that artery is protected.
[Dr. Christopher Beck]:
Yes. Protected a little bit more reliable in its course. I've had two. One was, we were going for, quote-unquote, "pleural effusion." It was like a little loculated thing that was high up. It was a ICU patient where we just had like a limited window. I could see where we went wrong with that one. Then the other one just routine, like is just as common as anything, like big pleural effusion. Then I'll also echo that sentiment and say, so those are my two, but I've also seen some with my partners, not a lot, still under like five at one of the hospitals that we do. That's also including, we have an interventional pulmonologist.
A lot of people doing thoracentesis, but here's what I'll say. It's very nice to be an interventional radiologist and being able to handle your own complications, like taking them back for intercostal embolization. The only thing that I'll say, like that could be a topic on of itself, but one of the things I like to do is like, so I've actually have a thoracentesis, like hemothorax-related complication. I put a little BB over where we entered. A little BB on the back.
Yes, it's actually, it's a really nice move because sometimes you get in there and you think you're going to know exactly which rib it is, but it's just like hitting the easy button. You can see it exactly. You know you're not done until you've seen that intercostal artery. That's nice. Other than that, it's just routine, like search and destroy mission. You just go and looking for the injured artery and then finding it. Thank you for bringing that up.
[Dr. Paul Lewis]:
As you're speaking, what did come to mind, no hemothoraces from thoracentesis, but from a lung biopsy I did have and yes, and taking the patient all the way through. I think that's another point if I can elaborate a little as far as who's doing the thoracentesis, diagnostic radiologist, interventional radiologist, or PA. Our hospital went through a course where, okay, diagnostic is doing the procedure or their PA is doing it. Then, say a pneumothorax or ex vacuo occurs or a hemothorax occurs, they get passed off to a new physician, where if I'm doing the thoracentesis or my PA is doing it, it's the same, at least the same team. I'm speaking to them from the beginning and to the finish. They may feel better continuity of care. As far as my reasoning, we have already built a rapport when it comes down to more urgent situation. I think that it's best for the patients.
[Dr. Christopher Beck]:
I'll echo that sentiment. I also think whenever it's your own complication, for me, like the sense of urgency is like through the roof. Aside from the patient, no one feels worse about that and wants to make that right in the most possible way. I always feel like I'm the most-- I'm certainly one of those motivated persons when it comes to taking care of complications. I think when it's like a self-alley-oop like that, when it's like from your case to the next, I'll tell you what, so having a complication is terrible, but being able to fix it feels fantastic. Being able to give someone like a speedy, quick resolution, obviously avoidance is the best, but like this is the next best thing, being able to fix your own problems.
[Dr. Paul Lewis]:
Yes. I think the timing's faster if it's us. Of course. If you're there in the beginning.
[Dr. Christopher Beck]:
Anything to talk about as far as re-expansion pulmonary edema?
[Dr. Paul Lewis]:
Yes. I think it's certainly a dreaded complication. The mortality rate, 20%, you're coming in for an outpatient procedure, and then they're told, well, there's a 20% chance you may die from a re-expansion pulmonary edema. That's based on one of the first studies of RPE. That was nine patients. That's where they got the 20% mortality.
[Dr. Christopher Beck]:
I'm so glad you said that. I didn't know that. Certainly that changes everything. One, how did they get 20% from nine patients? Two, that puts some context into that number. Because you will hear 20% like mortality rate of a rare complication. If you have re-expansion pulmonary edema, there's a 20% mortality associated with it. Can we get that paper from you? We'll link to that too, if you have it.
[Dr. Paul Lewis]:
Yes.
[Dr. Christopher Beck]:
Oh, fantastic.
[Dr. Paul Lewis]:
It was from a review, but I'll get to-
[Dr. Christopher Beck]:
Thanks, man.
[Dr. Paul Lewis]:
--the direct thing. Also to mention in that study, the people that did have the re-expansion, the range of volume taken was 1 to 4 liters. I think, again, we hear one statistic and we just hang on it. We don't look at that. Then incidence is less than 1%. It's again, as I'm reaching 1,000, I'm watching a little bit more carefully for this clinical science of RPE, but then we look at it and say, "What's the cause of the RPE?" There's still a lot of unknowns or some unknowns about the pathophysiology of why. Is it clinically what that translates into? Is it I'm taking too much? Am I taking it too fast?
Thankfully, those are two variables we control, controlling the controllable. We can decrease our volume if we certainly have that clinical concern. We can just decide to take less or we take it slower, and, not to be a commercial, but the Laborie pump, it gives me that control. As far as the vacuum containers, it's 0 or 60. Go to the pump. I can take it very, very slow, even painfully slow, which I think some of our sonographers take advantage of.
Bilateral Thoracentesis: Single Session or Staged Approach?
While performing thoracentesis on both sides in one session is statistically safe, experienced clinicians often prefer a staged approach, particularly for inpatients, to allow for symptomatic evaluation and reassessment of the remaining effusion. Prioritizing the larger effusion for initial drainage often addresses both diagnostic and therapeutic goals, potentially reducing the need for a second procedure.
[Dr. Christopher Beck]:
Doing bilateral thoracentesis on the same day, or space them out? What do you do?
[Dr. Paul Lewis]:
In general, I do plan the safe side for inpatients. I'll do the right side day one, the left side day two. Just because we have that time, I choose the larger of the two sides as far as a pleural effusion. Outpatient setting, we certainly try to do it at two different time points. Statistically, it's safe to do bilateral in one sitting.
[Dr. Christopher Beck]:
I'll echo that. We are very much, we like to split our thoras up. Especially for inpatients, Monday, right side, Tuesday, left side. Same with you; we pick the bigger of the two effusions. What always surprises me is we have the next procedure planned for the next day, and sometimes, like our medicine colleagues or surgery colleagues, once we remove that fluid, I don't know, maybe they're getting dialysis or maybe a number of a thousand different things happen. Sometimes the next one doesn't really need to be done because it's either decreasing your size or now because we did one side, they're asymptomatic. That was really the goal. Either we have the amount of fluid for the diagnostic part and now we're going to get to the bottom and treat the underlying cause.
Sometimes spacing them out works to our advantage or works to the patient's advantage and not having them put through another procedure that maybe isn't as indicated. Certainly, for plenty of our patients will do a bilateral same day.
Monitoring for Thoracentesis Complications During Fluid Removal
Safe and effective fluid removal during thoracentesis hinges on precise volume management and real-time patient feedback. For first-time thoracentesis patients, clinicians are advised to limit removal to 1 to 1.5 liters, monitoring for symptoms such as coughing, chest discomfort, or signs of re-expansion pulmonary edema. Dr. Lewis highlights the importance of involving patients throughout the procedure, advising them to communicate when symptoms arise to guide when to slow or stop fluid removal.
[Dr. Christopher Beck]:
I want to talk about removal of fluid. First, so a totally naive patient, never been tapped before, do you have a number in your head to what you will not go over?
[Dr. Paul Lewis]:
I think overall guidelines and/or just convention is limiting at one liter, and I think the prudent interventionist would stop there at one liter. That said, if people have had prior ones, look at the record as far as how much has come out and then I'm comfortably going up to two liters. I think more and more experience I've had over these six years, I went through my case logs, saw that I did 944 personally, but again, with more experience, I'm getting more and more liberal with how much I get or how much I take and then we talk about total volume versus the drainage.
I say the drainage, at least in the beginning, was to take a liter, but we take off that diagnostic sample. Our pathologists want 240 milliliters of fluid. We would typically, first-time patient, take 1,200 milliliters or 1.2 liters comfortably and watching them throughout the course, telling the patient, once we get our diagnostic sample, you tell us when to stop because then we transition from diagnostic to that therapeutic spectrum, and that's usually because, one, they're coughing, again, re-expansion or they have new chest pains or they're just tired of the procedure.
[Dr. Christopher Beck]:
Whenever you're telling your patients or coaching your patients, hey, give us some feedback and tell us how you're feeling. You coach them on, I think you said, breathlessness, coughing, chest pains. Those are the things that would clue you to, "Hey, let's think about stopping at about this volume."
[Dr. Paul Lewis]:
Yes. Those are great.
[Dr. Christopher Beck]:
How about how you take off the fluid? Are you hand pulling it out, vacuum suction, wall suction? What you got?
[Dr. Paul Lewis]:
That's a great question. Some look at it as that's the procedure. They're taking the fluid. It's placing the needle, the procedure, is pulling the fluid, the procedure. Again, I talked about as far as a diagnostic therapeutic patients where they're getting both diagnostic samples for a long time, I would do it manually. I'm taking off four 50cc syringes that fill up the 60cc's, and I spend that time doing that. Then we hook them up to vacuum containers, and I said that was before or early on. I learned since that time about the Laborie Renova Centesis Center or aspiration pump. First learned about that in paracentesis, but now has expanded indications for thoracentesis. Now we use that exclusively for thoracentesis.
[Dr. Christopher Beck]:
How does it work? What's the deal with it?
[Dr. Paul Lewis]:
Yes, it's different than a vacuum container. The vacuum container, it really sucks. The pump. The pump more pulls it. It's almost looking at it, so a rolling dial that creates small vacuums and then a continuous slow pull. I think one of the biggest benefits and some apprehensions is I looked at the pump in paracentesis and I did an executive MBA program, and my question was, well, is it worth it? Is using this pump faster? I first learned about it on SIR Connect.
[Dr. Christopher Beck]:
Okay. Or a BackTable episode, maybe?
[Dr. Paul Lewis]:
Yes, that's right. Both of them. A lot of different places. There's information out there. One of the concerns was, oh, well, I want objective information on it, and I buy a poster on SIR Connect. Part of my MBA program, we have to set up a project, and that's where I looked at using the pump for paracentesis, and it showed on average, we save nine minutes, which it adds up.
[Dr. Christopher Beck]:
Oh, no doubt. When you think about how many pairs we might do in a day, like nine minutes is, that's nothing to sneeze at, especially with a little short procedure, no doubt.
[Dr. Paul Lewis]:
Yes. Our sonographers, they liked it. It's cleaner. It's faster. It's more convenient. Patients also, they really liked it as far as from a paracentesis standpoint. My survey afterwards to the patients was that they would consider going to one place or another if they used the pump or didn't, and all of the patients and the sonographers recommended other sites to use it. That said, really, the walk away from that study in a clinical imaging journal, it's out there. You can find it.
[Dr. Christopher Beck]:
Hey, we'll link to it, man. We'll link to it. You give it to us. We'll link to it.
[Dr. Paul Lewis]:
Great. Thank you. Is that it is faster. It's more efficient, and that's great in paracentesis, but when we talk about thoracentesis, certainly concern is it too fast, and that's what's great about this pump. With our vacuum containers, as you know, it's 0 or 60. With a pump, we can have 0 through 60. Looking at this ahead of time and addressing things for my colleagues, as far as the pump itself, it has a circular dial. It has markings from seven o'clock to five o'clock, and so you can dial it either right there at 7:30, eight o'clock, or turn it all the way around to five o'clock, and that's 100%.
Looking at that variability and that versatility, I did it with just water, but to drain 500 milliliters at that 7:30 to eight o'clock position, it takes 15 minutes and 35 seconds, so 15.5 minutes to drain 500 milliliters if you want to do it that slowly. On the other side, how fast can you do it draining that same 500 milliliters? I was able to do it in about a minute.
[Dr. Christopher Beck]:
Okay. And anything in between.
[Dr. Paul Lewis]:
Yes, and anything in between, so it's almost 15 times difference. That draining 500 milliliters in 15 minutes is certainly slower than you would have with a vacuum container, and with a pump, you have control, so you could start out fast and then slow it down. As far as we're here talking about best practices and what I do, we generally put it at 11 to 12 o'clock, and that drains the 500 milliliters in about one and a half minutes and haven't had any complications.
[Dr. Christopher Beck]:
Okay. If you're getting to that area where the patient's starting to cough a little bit, coughing, but still tolerating it, you just dial it back a little bit and continue to pull? Even if you know you still got fluid left in the tank?
[Dr. Paul Lewis]:
Absolutely. Again, I usually place the needle and have been able to work with the sonographers, where they manage the tube themselves. Instead of them standing there pinching a little bit more of the tube, they can just turn the dial back, so they reach that nine o'clock, eight o'clock, or 7:30 position, and it's draining really slow. Then there's less pinching for the patient. It makes it more enjoyable, I think, for everyone.
[Dr. Christopher Beck]:
Okay. Let me ask you this. Say you're draining the patient. Let's say you happen to be in the room for the end of it, and you start seeing that the patient's asymptomatic, but you start seeing that the catheter's pulling fluid air, fluid air, in really short succession, like that staccato noise that you get when it's pulling air and fluid at the same time. What do you do? Do you keep pulling, or do you stop at that point?
[Dr. Paul Lewis]:
We generally stop. I think it's either we've been managing the tube and pulling it out, and now air's coming in through the subcutaneous, or likewise, so we want to end it.
[Dr. Christopher Beck]:
Okay, got you. Just one thing, I just jotted down in my notes, like mention something just a little bit different in our practice than yours. For our thoracentesis-naive patients, our number in our head is 1.5 liters for like our very first patient. I think there's always like operator discretion and certainly like bigger patients can tolerate more than, like you said, if you have someone who's like come in routinely and they're always having two liters taken off, we'll work to whatever number is appropriate for them. That's like the number in our head that's like for our very first patient when we're trying to pull off fluid, and that's where we'll start.
Troubleshooting, we already talked about complex effusions. Anything to talk about really, with like if you have a really small effusion or you just treat it like any fluid cavity that we go after, right? Real-time ultrasound guidance.
[Dr. Paul Lewis]:
Yes. Very similar. Approaching it, real-time ultrasound guidance. Get it in, get it out, and then move, finalize.
Podcast Contributors
Dr. Paul Lewis
Dr. Paul Lewis is an interventional radiologist and assistant professor with UPMC in Pittsburgh, Pennsylvania.
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Cite This Podcast
BackTable, LLC (Producer). (2024, June 11). Ep. 453 – Thoracentesis Best Practices [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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