Ultrasound and Risk
Thoracic ultrasound guidance
Real time bedside thoracic ultrasound guidance is gold standard for the insertion of non-emergency pleural drains for management of pleural fluid.
Pre-insertion risk assessment
The admitting consultant should be informed prior to the procedure and again informed if there are any complications resulting from the procedure.
The decision to use needle aspiration or pleural drain should consider the operator's experience/ competence in each of these procedures.
Check correct patient, correct site clinically and radiologically.
Obtain written consent (may waiver in emergency situations and critical care areas).
- Insertion of non-emergency pleural drains should not take place out of normal day time working hours.
- Pleural aspirations and pleural drains should be inserted in a clean area using full aseptic technique.
- Patient privacy should be respected and wherever possible insertion of a pleural drain should be performed in a specifically dedicated procedure room (as defined by NSW Ministry of Health) or for isolated patients within their isolation room.
Underlying abnormal lung pathology
- Needle aspiration for management of pneumothorax is not recommended as first line management in a patient with underlying abnormal lung pathology.
- Differential diagnosis between a pneumothorax versus bullous disease or complete lung consolidation versus large pleural effusion requires careful radiological assessment.
- Drainage of a pleural space that has had prior surgical intervention must only be performed after consultation with the patient's cardiothoracic surgeon/consultant physician.
- Lung that is densely adherent to the chest wall throughout the hemi thorax is an absolute contraindication to pleural drain insertion.
- There is significant risk of haemorrhage when inserting a pleural drain in any patient with a coagulopathy or platelet deficiency.
- In non-emergency situations, coagulopathy should be corrected prior to insertion of a pleural drain or pleural aspiration.
- Insertion of a pleural drain or pleural aspiration should be avoided in anti-coagulated patients until international normalized ratio (INR) <1.5 or platelets >50 x109/L. It is recommended not to give heparin/clexane on the day of insertion or if already administered, to delay insertion until six hours after delivery of the last dose.
- Antibiotic prophylaxis is not recommended for non-trauma patients requiring a pleural drain.
- Antibiotic prophylaxis should be considered for trauma patients requiring pleural drains, especially after penetrating trauma.
- A single dose of cephazolin 2g, given intravenously, provides adequate antimicrobial cover. Where cephazolin is contra-indicated, a single dose of vancomycin 15mg/kg, given by intravenous infusion, is recommended.
Non invasive ventilation (NIV)
In the presence of a pneumothorax, the use of NIV is not contraindicated once the patient has an intercostal catheter inserted with a patent pleural drain which is oscillating and connected to an under water seal drainage system (UWSD) bottle.