Thoracentesis in Pediatric Patients

Thoracentesis in Pediatric Patients

Thoracentesis is a diagnostic and therapeutic procedure involving the removal of pleural fluid through needle aspiration. In pediatrics, it requires special considerations due to patient size and cooperation.

Key Points

Essential diagnostic tool for pleural effusions
Both diagnostic and therapeutic applications
Requires ultrasound guidance in children
Age-appropriate equipment selection crucial
Usually performed under sedation in children

Indications

Diagnostic:
- Unexplained pleural effusion
- Suspected empyema
- Suspected malignant effusion
- Parapneumonic effusions
Therapeutic:
- Respiratory distress from effusion
- Large symptomatic effusions
- Infected pleural collections

Pre-procedure Preparation

Patient Assessment

Clinical evaluation
- Vital signs
- Respiratory status
- Coagulation status
- Volume of effusion
Imaging review
- Chest X-ray
- Ultrasound
- CT scan if available

Required Equipment

Category	Items
Sterile Equipment	Sterile gloves Sterile drapes Cleaning solution Gauze packs
Procedure Kit	Thoracentesis needle (age-appropriate) Syringes (various sizes) Three-way stopcock Collection tubes
Emergency Equipment	Chest tube kit Local anesthetic Emergency medications Oxygen supply

Consent and Documentation

Informed consent from parents/guardians
Documentation of:
- Indication
- Risks discussed
- Expected benefits
- Alternative options
Time-out procedure
Site marking

Detailed Procedure Steps

1. Patient Positioning

Sitting position preferred
- Upper body supported
- Arms resting on table
- Head supported
Alternative: Lateral decubitus
- Affected side up
- Upper arm over head

2. Site Selection

Ultrasound guidance mandatory
- Mark maximum fluid pocket
- Identify safe needle path
- Measure fluid depth
Typical entry point:
- 1-2 intercostal spaces below effusion top
- Posterior axillary line
- Above rib (avoid neurovascular bundle)

3. Sterile Technique

Hand hygiene
Sterile gown and gloves
Skin preparation
- Chlorhexidine or betadine
- Allow to dry completely
Sterile draping

4. Anesthesia

Local anesthetic infiltration
- 1% lidocaine
- Maximum 4-5mg/kg
- Layer by layer infiltration
Consider sedation based on:
- Patient age
- Anxiety level
- Procedure complexity

5. Needle Insertion

Initial needle advancement
- Perpendicular to skin
- Just above rib
- Maintain negative pressure
Fluid aspiration
- Collect required samples
- Monitor volume removed
- Watch for complications

Pleural Fluid Analysis

Essential Tests

Test Category	Specific Tests	Collection Tubes
Basic Studies	Cell count & differential Protein & LDH Glucose pH	Purple top, Red top
Microbiology	Gram stain Culture & sensitivity AFB stain/culture	Sterile container, Blood culture bottles
Special Studies	Cytology Triglycerides PCR studies	Based on test requirements

Interpretation Guidelines

Parameter	Transudate	Exudate
Protein ratio (fluid/serum)	<0.5	>0.5
LDH ratio (fluid/serum)	<0.6	>0.6
Fluid LDH	<2/3 upper normal serum	>2/3 upper normal serum

Complications & Management

Immediate Complications

Pneumothorax
- Most common complication
- Monitor breathing
- Post-procedure chest X-ray
Pain
- During procedure
- Post-procedure site pain
Bleeding
- Local site bleeding
- Hemothorax (rare)

Delayed Complications

Re-expansion pulmonary edema
Infection
Chronic pain

Prevention Strategies

Proper technique
Ultrasound guidance
Volume limits
- 10-20 mL/kg maximum
- Monitor symptoms
Careful patient selection

Post-procedure Care

Monitoring

Vital signs
- Every 15 minutes for 1 hour
- Every 30 minutes for 2 hours
- Then as needed
Respiratory status
Pain assessment
Procedure site check

Imaging

Post-procedure chest X-ray
- Within 2-4 hours
- Earlier if symptoms
Follow-up imaging as needed

Further Reading