2 English reference thoracic puncture
Operation name: Thoracic puncture
4 chest puncture, another name for chest puncture; Pleural adhesion; Pleurocentesis; Thoracic puncture; thoracentesis
5 ICD code: 34.91015.1classified thoracic surgery/invasive diagnosis and treatment technology.
5.2 Overview Thoracic puncture is one of the most commonly used diagnosis and treatment techniques in thoracic surgery.
5.3 Thoracic puncture indications are applicable to:
1. If there is pleural effusion, it is necessary to clarify the nature of pleural effusion or extract pleural effusion to understand the lung condition.
2. Treating unilateral or bilateral pneumothorax, hemothorax or hemopneumothorax by aspiration, drainage and thoracic decompression.
3. Relieve dyspnea caused by massive pleural effusion.
4. Inject antineoplastic drugs into chest cavity or promote pleural adhesion.
Some early chest infections or empyema can be cured by repeated aspiration and injection of antibiotics.
5.4 preoperative preparation 1. The choice and location of puncture point should be in the second intercostal anterior space of clavicle midline if aspiration is performed in the chest cavity, and in the 7th and 8th intercostal space of scapular posterior line, axillary posterior line or axillary midline if aspiration is performed. If it is a puncture of encapsulated effusion or a small amount of effusion, it should be located according to chest radiograph or ultrasound.
2. The chest puncture kit is provided by the hospital or used as a disposable commodity.
5.5 anesthesia and *** 1. Disinfect the anaesthetized skin. After spreading the bed sheet, first pitch the puncture point with 1% ~ 2% lidocaine or procaine, then infiltrate the anaesthetic into the chest wall to parietal pleura. After confirming that the gas or liquid pumped back by the syringe has entered the chest cavity, pull out the anaesthetic needle.
2.*** is usually sitting posture. If the condition is serious, you can use a semi-recumbent position.
5.6 Operation steps 1. Needle the skin. 18, and then use a thoracic puncture needle to enter through the skin puncture hole. The needle should enter the chest along the lower part of the intercostal space and the upper edge of the next rib. This can not only avoid damaging intercostal vessels, but also be used as a sign of entering pleural cavity to avoid damaging lung tissue by acupuncture too deeply. Experienced doctors can feel frustrated when the needle penetrates the pleural cavity, indicating that the needle has entered the thoracic cavity (Figure 5. 1. 1 1).
2. When the surgeon adjusts the position of the needle and can pump out gas or liquid smoothly, the assistant will fix the puncture needle on the skin surface with vascular forceps to avoid the needle from shifting. The puncture needle is connected with a 30ml or 50ml needle tube through a latex tube with a length of 10cm. When the needle tube is full, the assistant will clamp latex tube with another vascular clamp, remove the needle tube to discharge gas or liquid to prevent air from entering the chest cavity. Then connect the needle tube with latex tube and continue to attract.
5.7 Precautions during operation 1. During the puncture, the patient's breathing and pulse should be closely observed. When individual patients feel dizzy or syncope, they should immediately stop the operation and deal with the patients accordingly.
2. The puncture needle should not go too deep into the chest to avoid damaging the lung tissue. Generally, 0.5 ~ 1.0 cm needle should be used to enter the chest cavity. In the process of needle aspiration, if the patient suddenly coughs, the needle should be quickly drawn into the chest wall, and then the needle should be sucked out after the patient's cough stops.
3. In principle, it is recommended that all liquids be discharged during each puncture. However, for a large number of pleural effusion, the first drainage generally does not exceed 1000ml, and the next drainage does not exceed 1500ml. If the lung is compressed for a long time due to pneumothorax or hydrops, the suction speed should not be too fast to avoid the occurrence of reexpansion pulmonary edema. When the patient complains of discomfort in chest tightness, the operation should be stopped.
ICD code: 34.9 102 6. 1 Classification Thoracic Surgery/Pleural Surgery/Surgical Treatment of Pneumothorax/Surgical Treatment of Spontaneous Pneumothorax.
6.2 About Primary Spontaneous Pneumothorax Primary spontaneous pneumothorax is caused by rupture of subpleural pulmonary bulla, which is often located at the tip of the lung. Most patients are slim. Withers et al investigated a group of recruits, and found that the average height and weight of those with pneumothorax were generally 5cm higher and lighter 1 1kg(25 lbs) than other recruits. The alveoli at the apex of the lung bear a large average tension, which leads to the formation of subpleural pulmonary bullae. Smokers are prone to primary spontaneous pneumothorax. It has also been reported that primary spontaneous pneumothorax has a family tendency, and those with simple HLA type A2 and B40 are more prone to pneumothorax. Under normal circumstances, the resting functional residual capacity (FRC) of lung accounts for 36% of vital capacity, and the pressure is always higher than that of pleural cavity. If there is communication between alveoli and pleural cavity, gas will enter the pleural cavity from alveoli, the pressure gradient will disappear, and the gas communication will stop. Healthy people can well tolerate the decline of vital capacity, such as lung function has been damaged before pneumothorax, and the decline of vital capacity may lead to insufficient alveolar ventilation and respiratory acidosis. Animal studies show that there is no corresponding change in lung perfusion during pneumothorax, but the reduction of ipsilateral lung ventilation leads to the decrease of ventilation/blood perfusion ratio of pneumothorax. The average level of PAO _ 2 caused by pneumothorax decreased from 65438±02.8 kPa(96 mmHg) to 6.8 kPa(565438±0 mmHg), and PAO _ 2 immediately recovered to its original level after lung inflation. But in human body, it takes a long time for PaO2 to recover, usually 30 ~ 90 min. The change speed of intrapulmonary shunt after pneumothorax disappears is also related to the duration of pneumothorax (Figure 5.3.1.1015.3. 1. 102).
The main symptoms of primary spontaneous pneumothorax are chest pain and dyspnea. About 64% of them have both, and it is rare to have neither chest pain nor dyspnea. It is reported that spontaneous pneumothorax complicated with Horner syndrome is caused by mediastinal displacement and sympathetic nerve traction. Primary spontaneous pneumothorax usually occurs at rest. There are 285 cases of pneumothorax reported in the literature, and only 24 cases are affected by strenuous exercise. If pneumothorax lasts too long, the incidence of reinflation pulmonary edema will increase when lung dilates.
The vital signs of patients with primary spontaneous pneumothorax are generally normal, but tachycardia may occur. The chest signs are as follows: the thorax on the pneumothorax side is full and the activity in respiratory circulation is weakened, there is no tremor in palpation, the percussion response is enhanced, the breathing sound is weakened or disappeared, and the trachea may shift to the opposite side; In patients with right pneumothorax, the lower edge of the liver may move down; Chest X-ray examination can confirm the diagnosis, 10% ~ 20% cases are accompanied by pleural effusion; Electrocardiogram examination of some patients found that the frontal QRS axis moved to the right, the R wave voltage in chest lead decreased, and the T wave was inverted, sometimes misdiagnosed as acute subendocardial myocardial infarction. If the pulse rate exceeds 130/min or hypotension or cyanosis occurs, tension pneumothorax should be suspected (fig. 5.3.1.103).
Primary spontaneous pneumothorax is easy to recur. Gobbel et al. followed up a group of 1 19 cases of spontaneous pneumothorax for 6 years, and found that 1 10 cases did not receive closed thoracic drainage for the first time, and 57 cases (52%) recurred ipsilateral. The recurrence rates of the second and third pneumothorax were 62% and 83% respectively. The average recurrence interval is about 7 months. Many chemicals, including quinacridine, talcum powder, hypertonic glucose solution and tetracycline, seem to be effective when injected into pleural cavity for the first time in order to produce pleural adhesion and prevent recurrence. Regarding whether talcum powder can cause pleural or lung tumors, the British Chest Association observed 2 10 cases of pleurodesis with talcum powder iodide 40 years ago, and found no increase in the incidence of mesothelioma and lung tumors.
Most primary spontaneous pneumothorax is treated by closed thoracic drainage. Injection of tetracycline or hypertonic glucose into pleural cavity for the first pneumothorax can reduce recurrence. If the affected lung leaks or cannot expand for a long time, thoracoscopic or thoracotomy should be performed to suture or remove the bullae at the tip of the lung and add pleural adhesion.
Many lung diseases may be secondary to spontaneous pneumothorax. Such as tuberculosis, silicosis, pulmonary fibrosis, lung abscess, primary alveolar carcinoma with bronchial obstruction and metastatic pleural disease, Marfan syndrome, etc. It has even been reported that spontaneous pneumothorax can be the first clinical symptom of AIDS. But chronic obstructive pulmonary disease and pulmonary cystic fibrosis are the most common.
Secondary spontaneous pneumothorax often aggravates the damaged lung function, and its clinical symptoms are far more serious than those of primary spontaneous pneumothorax. Most secondary spontaneous pneumothorax has dyspnea, and X-ray changes are often inconsistent with the severity of dyspnea. 57 cases of pneumothorax secondary to chronic obstructive pulmonary disease all had shortness of breath, among which 42 cases (74%) had chest pain. Because the respiratory reserve function of these patients has been partially or mostly lost, once pneumothorax occurs, it may be life-threatening. Comprehensive three groups *** 120 cases of secondary spontaneous pneumothorax, the mortality rate at admission was 16%. Among them, 3 cases died suddenly before placing closed thoracic drainage tube; 3 cases developed respiratory failure within 24 hours during the treatment; Respiratory failure occurred in 3 cases after 24 hours; In addition, 3 cases of gastrointestinal bleeding occurred during the follow-up treatment.
Secondary spontaneous pneumothorax is mostly caused by over-expansion of the original lung, with unvoiced sound at percussion, weakened tremor at palpation and lung breathing sound. When pneumothorax occurs, there is often no obvious difference between the two sides in physical examination. The diagnosis of secondary spontaneous pneumothorax is determined by chest X-ray. However, when pneumothorax occurs in chronic obstructive pulmonary disease, X-ray films can show localized pneumothorax or incomplete collapse of the diseased lung. Sometimes it needs to be differentiated from pulmonary bullae. CT scan is helpful to distinguish the primary lung lesions.
The initial treatment of secondary spontaneous pneumothorax is almost always closed thoracic drainage. Even if the pneumothorax is relieved, the symptoms can often be improved quickly after the gas is exhausted. Usually arterial blood gas has improved within 24 hours after intubation and drainage. If respiratory failure occurs and mechanical ventilation is needed, it is even more necessary to place a closed thoracic drainage tube. Some data even show that 29% ~ 35% of chronic obstructive pulmonary disease secondary pneumothorax often needs more than one thoracic drainage tube. The position of the chest tube should be carefully checked and located by X-ray and/or CT. A large mushroom latex tube should be used to place the catheter as high as possible in the pleural cavity. If there is continuous air leakage after intubation, continuous low negative pressure (18 ~ 20 cmH2O) should be given to discharge the pneumothorax as soon as possible, and the X-ray chest film should be reviewed within 24 hours. After placing chest tube drainage, the recovery of secondary pneumothorax is far more difficult than that of primary pneumothorax. Usually, the air leakage stops within 3 days after the lung is inflated. For secondary pneumothorax, due to chronic obstructive pulmonary disease, the average time of lung inflation is about 5 days, and after 7 days, 20% of secondary spontaneous pneumothorax continues to leak.
For pneumothorax caused by localized lung lesions, closed thoracic drainage should be performed. After short-term preparation, video-assisted thoracoscopy or thoracotomy should be considered to remove localized lung lesions. After the lungs are re-expanded, pleural friction or partial parietal pleura resection should be performed, resulting in "pleural adhesion". In patients with chronic obstructive pulmonary disease and pulmonary cystic fibrosis, the mortality rate of emergency thoracotomy is about 10%. Therefore, for cases of secondary spontaneous pneumothorax, whether early or delayed surgical treatment, intensive medical treatment before and after operation can not be ignored.
Dines et al reported that 57 cases of secondary spontaneous pneumothorax were treated by pleural puncture or closed drainage without thoracotomy. After 10 years of observation, 38 cases still had pneumothorax again. It is suggested that the recurrence rate of secondary spontaneous pneumothorax is above 50%. Luck et al. found that the recurrence rate of spontaneous pneumothorax secondary to pulmonary cystic fibrosis was 50% if only closed thoracic drainage was used. Therefore, measures should be taken to prevent recurrence as much as possible during the treatment.
The treatment of spontaneous pneumothorax should pay attention to two aspects, that is, purging pleural cavity gas and reducing the possibility of recurrence (Figure 5.3.1.104).
If the communication between alveoli and pleural cavity is closed, the gas in pleural cavity will be absorbed. Kircher and Swartzer believe that the rate of self-absorption is about 65,438+0.25% of the single chest absorption volume every 24 hours. If pneumothorax accounts for 15% of the chest cavity, it will take 12d to be completely absorbed. Therefore, patients whose pneumothorax accounts for less than 15% of the volume of unilateral chest cavity and whose clinical symptoms are not obvious may not be treated specially.
See figure 5.3.1.1.11.
6.3 Thoracic puncture indications are applicable to:
1. Unilateral or bilateral pneumothorax and hydropneumothorax can play the role of exhaust, drainage or decompression.
2. Patients suspected of chest infection or tumor are used for injection drug therapy or specimen examination.
6.4 preoperative preparation 1. Select appropriate puncture points to puncture empty needles, local anesthetics and standing supplies.
2. The patient takes supine position, semi-recumbent position or sitting position, and chooses 1 or the second intercostal space slightly outside the clavicle midline, the fifth intercostal space in the axillary midline or the second posterior intercostal space beside the spine (chest top pleural effusion).
6.5 Operating Steps 1. Local disinfection and hole towel laying, local anesthesia with 2% lidocaine at the selected puncture point.
2. The puncture needle slowly penetrates along the upper edge of the next rib. When penetrating parietal pleura, you can feel the resistance of the needle suddenly disappear, and then you can pump air.
3. The puncture needle shall not enter the pleural cavity more than 0.5cm, so as not to stab the swollen lung tissue, and clamp it with vascular forceps when necessary. When the fluid at the top of the chest and pneumothorax are pumped out through the second posterior intercostal space beside the spine, the patient takes a sitting position, and the affected hand is placed flat on the opposite shoulder (to abduct the puncture scapula), and the operator is behind the patient. After local anesthesia, use 9 # or 12 # long puncture needle to puncture slowly through the midpoint of the connecting line between spinous process and the upper angle of scapula, so that the patient can enter the top of pleural cavity and extract the gas and liquid from the top of pleural cavity (Figure 5.3.
4. When the syringe is full, clamp the hose with a vascular clamp and unplug the syringe to drain and exhaust, so as to avoid inhaling air; If a large amount of gas is pumped out and it is difficult to pump out or the chest pressure is high, it should be changed to closed chest drainage.
6.6 Precautions during operation: 1. If the patient is a simple hydropneumothorax and the lung is severely compressed for a long time (1 week or more), the total amount of liquid and gas extracted at one time should not exceed 1500ml. If the patient has cold sweat, syncope or sudden cough and chest tightness, the operation should be stopped immediately.
2. Observe the nature and smell of the extract and gas, and make necessary tests, cultures and cytological examinations according to the situation.
7 ICD code: 34.9 103 7. 1 classified thoracic surgery/pleural surgery/surgical treatment of empyema.
7.2 Empyema pleural effusion is called empyema. In recent years, due to the improvement of medical conditions and the continuous renewal of antibiotics, the incidence of empyema has dropped significantly. However, due to the continuous emergence of drug-resistant bacteria and the extensive development of thoracic surgery, empyema still occurs from time to time. According to the course of disease, it can be divided into acute empyema and chronic empyema.
7.2. 1 1. Etiology of acute empyema: mainly the focus of lung infection. When pneumonia directly invades the pleura or lung abscess and other lesions rupture, bacteria directly enter the pleural cavity, forming empyema or empyema. If there is anaerobic infection, it will form putrefying empyema, which contains necrotic tissue and is accompanied by stench.
After chest trauma and operation, hemoptysis, effusion, bacterial contamination and foreign bodies remain in the chest cavity, and trachea, bronchus or digestive tract communicate with pleural cavity, forming empyema.
Adjacent organ infections, such as liver abscess, subphrenic abscess, purulent pericarditis, mediastinal abscess, spontaneous esophageal rupture, mediastinal teratoma infection rupture, mediastinal lymphadenitis, etc., can all cause empyema.
Blood-borne infections are mostly caused by septicemia and septicemia.
Pathology: Pleural bacterial infection causes tissue inflammatory changes, pleural congestion, edema and increased permeability, which makes the pleural surface rough. There is yellowish transparent exudate, a small amount of fibrin deposition and polymorphonuclear leukocytes in the chest cavity. This stage is acute or exudation. At this time, if active and effective treatment is given and the effusion is discharged in time, the lung can be fully expanded and has little effect on lung function. If it is not treated in time and effectively in the exudation stage, with the increase of bacterial invasion, the number of white blood cells will gradually increase, the proliferation of vascular cells and fibroblasts will accelerate, and a large amount of fibrin will be deposited on the surfaces of viscera and parietal pleura, especially on the surface of parietal pleura, and the exudate will turn into purulent fibrin stage. Cellulose membrane is soft and fragile, and gradually becomes tough from organization, forming pleural adhesion, localized empyema and localized or encapsulated empyema. If the infection is not controlled and spreads to the whole chest cavity, it will form a total empyema. Excessive pleural empyema compresses the lung tissue and collapses it, pushing the mediastinum to the opposite side, affecting the respiratory and circulatory function.
Because the amount of fibrin and white blood cells contained in exudate is different, the properties of pus are also different. Empyema caused by staphylococcus aureus, because the pus contains a lot of fibrin and pus cells, the pus is sticky and easy to form adhesion, resulting in multilocular pus cavity. Empyema caused by hemolytic streptococcus is thin and yellowish. The empyema caused by Escherichia coli and Alcaligenes faecalis is thin, smelly, with serious tissue necrosis, which is not easy to restrict the flow and often forms a whole empyema.
Clinical manifestations and diagnosis: Patients often have high fever, chest pain, cough, expectoration, shortness of breath, loss of appetite and general malaise. Patients with bronchopleural fistula can cough due to the change of * * *, and cough up a lot of pus and phlegm. Most patients show acute symptoms, but they can't lie flat, or even cyanosis due to dyspnea. The intercostal space of the affected side is filled, the respiratory activity is reduced, the mediastinum is displaced to the healthy side, the voice twitch is weakened, and the percussion sounds. Auscultation breath sounds weaken or disappear. Purulent pneumothorax coexists, with drum sound in the upper part of the chest and solid sound in the lower part.
X-ray examination showed dense shadows caused by pleural effusion. When there is a small amount of stagnant water (100 ~ 300ml), the costal diaphragm angle becomes blurred and blunt, and when there is moderate stagnant water (400 ~ 100~300ml), it will show an arc-shaped concentrated shadow. When empyema and pneumothorax coexist, the gas-liquid plane can be seen. Lung collapse and mediastinum moving to the healthy side can be seen in the whole empyema. Localized empyema often presents as a wrapped shadow. CT scanning and MRI examination are of special significance in the diagnosis and localization of multilocular localized empyema (Figure 5.3.2. 10 1, 5.3.2.6438+002).
Thoracic puncture, sputum smear, bacterial culture and drug sensitivity test under the guidance of X-ray localization and B-ultrasound can make a clear diagnosis and guide the selection of sensitive antibiotics.
7.2.2 2. Etiology of chronic empyema:
(1) The diagnosis of acute empyema is delayed, puncture and drainage are not timely, or drainage is done, but the drainage site is not suitable, the drainage tube is too thin, cellulose is deposited, and blood clots are blocked, which leads to poor drainage; The drainage tube is inserted into the abscess cavity too deeply and too high, and the drainage tube is pulled out too early, resulting in pus retention; The pus cavity is multilocular, leaving a pus cavity without drainage.
(2) The pathogenic bacteria are drug-resistant pyogenic bacteria, tuberculosis, fungi and amoeba. It can also become a "shelter" for bacteria because of the residual foreign bodies in the pus cavity, which can not be removed in time, and become chronic.
(3) Empyema complicated with persistent bronchopleural fistula, esophagogastrostomy fistula, and osteomyelitis of ribs or vertebrae leads to the persistent infection focus of empyema, which leads to the long-term unhealed empyema.
Pathology: Pleural cavity has accumulated pus for a long time, and a large amount of cellulose is deposited on the pleura, which is gradually thickened and organized, forming a fibrous layer with a thickness of 0.3 ~ 2 cm, and granulation tissue is on the surface. Tuberculous empyema has caseous substance and calcification. Due to the contraction of fibrous tissue on parietal pleura, the intercostal space is narrowed and the cross section of ribs is triangular. Intercostal muscular atrophy fibrosis, thoracic subsidence, scoliosis, mediastinum displacement to the affected side, and increased diaphragm adhesion. The fibrous layer of the visceral layer is tightly wrapped on the lung surface, which makes the lung unable to expand and seriously affects the respiratory function. Due to long-term chronic hypoxia, patients may have clubbed fingers (toes). Chronic infection poisoning causes amyloidosis of liver, kidney and spleen. Some chronic empyema directly festers, penetrates the intercostal space and forms an abscess on the chest wall.
Clinical manifestations and diagnosis: due to long-term infection and consumption, patients have low fever, loss of appetite, emaciation, malnutrition, fatigue, anemia, hypoproteinemia and so on. Examination showed chest subsidence, intercostal narrowing, respiratory activity weakened or disappeared, mediastinum shifted to the affected side, scoliosis, clubbed fingers, percussion sound, auscultation breath sound weakened or disappeared.
Chest X-ray examination showed pleural thickening, intercostal space narrowing, mostly ground glass blur with increased density, mediastinum shifting to the affected side and diaphragm elevation. Chest tomography, CT scanning and MRI can further determine the location and size of abscess cavity and whether there is any lesion in the affected lung. Thoracic puncture and bacterial culture still have guiding significance for diagnosis and treatment. Finding out the cause and clarifying the pathological nature can improve the success rate of operation.
7.2.3 3. Treatment principles The treatment principles of acute empyema include systemic support therapy, anti-infection and pus drainage.
(1) Whole body support therapy: Encourage patients to eat, especially a diet with high calorie, high protein and high vitamins, and pay attention to supplementing electrolytes. Those with critical illness and weak constitution should be given high nutrition, intravenous infusion of plasma and albumin, and a small amount of new blood should be added many times to correct anemia and increase resistance.
(2) Anti-infection: Puncture the chest cavity as soon as possible to extract pus for bacterial culture and drug sensitivity test, select sensitive and effective antibiotics, and control the disease as soon as possible.
(3) Drainage of pus: In the early stage of acute empyema, pus is mostly thin, and it is easy to extract pus through thoracic puncture. In case of rapid development of the disease, thick accumulation of pus, critical condition with poisoning symptoms, especially when pus is produced rapidly after thoracic puncture, closed thoracic drainage should be carried out in time, and empyema complicated with bronchopleural fistula or esophago-pleural fistula should also be drained.
The treatment principles of chronic empyema include the following three aspects.
(1) Chronic empyema often requires surgical treatment, with the aim of removing foreign bodies, eliminating abscess cavities and preserving and restoring lung function as much as possible. When the amount of pus is less than 50 ml every day, surgery is usually required. Nutrition should be strengthened before operation, hypoproteinemia and anemia should be corrected, blood transfusion should be repeated, and effective antibiotics should be selected to control infection.
(2) Adjust the drainage tube to ensure the full drainage of pus and make necessary preparations for radical operation. The position of the drainage tube should be close to the bottom of the abscess cavity, but not too low to avoid narrowing the abscess cavity and blocking the drainage nozzle. The diameter of the drainage tube generally requires that the inner diameter should reach 1 ~ 1.5 cm, and it should go deep into the abscess cavity for 2 ~ 3 cm, and a side hole should be left to facilitate full drainage. When there is less pus, the drainage tube can be cut off and changed to open drainage, but attention should be paid to the fixation of the drainage tube to prevent it from falling into the pus cavity. When the drainage tube is gradually withdrawn, the thin drainage tube should be replaced to promote the closure of the abscess cavity.
(3) The choice of operation should be based on the patient's condition, especially whether there is tuberculosis cavity, bronchiectasis, severe fibrosis and bronchopleural fistula in the lung. Commonly used surgical methods include pleural fibreboard peeling, thoracoplasty (intrapleural thoracoplasty) and pedicled omentum filling. Extrapleural thoracoplasty and pleuropneumonia resection are rarely used because of large injury and low success rate.
7.3 Indications Thoracic puncture is suitable for diagnostic puncture of patients with unknown pleural effusion; A large number of pleural effusion compression, leading to respiratory and circulatory disorders; After chemotherapy for tuberculous pleurisy, the poisoning symptoms were relieved, and there were still many hydrops. Empyema and empyema patients; Pneumonia complicated with pleurisy and more pleural effusion; Traumatic hemopneumothorax; Empyema or malignant pleural effusion requires intrathoracic injection of drugs.
7.4 Contraindications: The patient is in critical condition, with severe bleeding tendency, massive hemoptysis, inflammatory lesions at the puncture site, allergic to * * * *, pleural adhesions and pleural cavity disappearance, so it is not suitable for this operation.
7.5 Supply and prepare 1 chest puncture kit, including 12 or 16 chest puncture needle with latex tube, tweezers, hemostatic forceps, 5ml syringe and needle, 50ml syringe, gauze, towel and dressing bowl, and several sterile test tubes (routine, biochemical, bacterial and pathological specimens, etc.). Use anticoagulant if necessary).
7.6 Anesthesia and *** 1. Disinfect the anaesthetized skin. After spreading the bed sheet, first pitch the puncture point with 1% ~ 2% lidocaine or procaine, then infiltrate the anaesthetic into the chest wall to parietal pleura, and pull out the anaesthetic needle after the syringe withdraws the liquid to confirm that it has entered the chest cavity.
2.*** is usually sitting posture. If the condition is serious, you can use a semi-recumbent position.
7.7 Operation method 1. The patient sits in an armchair with his arms flat on the upper edge of the backrest and his head resting on his forearm; Severe patients can take an inclined posture on the sickbed, lift it on the affected side, put it under their heads, or stretch over their heads to open the intercostal space.
2. The puncture site should be located at the chest percussion, generally between the 79th humerus at the subacromial angle line or the 56th intercostal at the axillary midline. For encapsulated effusion, the puncture site should be determined according to the results of X-ray or ultrasonic examination.
3, the performer wearing a mask and sterile gloves, assistant to help open the chest bag, puncture site in accordance with the conventional disinfection, towel local anesthesia, should be step by step infiltration of parietal pleura.
4. Check whether the puncture needle is unobstructed. If there is no blockage, hold the latex tube at the end of the needle with a hemostatic forceps.
5. Needle the skin. 18, and then use a thoracic puncture needle to enter through the skin puncture hole. The needle should enter the chest along the lower part of the intercostal space and the upper edge of the next rib. This can not only avoid damaging intercostal vessels, but also be used as a sign of entering pleural cavity to avoid damaging lung tissue by acupuncture too deeply. Experienced doctors can feel frustrated when they needle into the pleural cavity, indicating that the needle has entered the thoracic cavity (Figure 5.3.2. 1 1).
6. When the operator adjusts the position of the needle and can pump out the liquid smoothly, the assistant will fix the puncture needle on the skin surface with vascular forceps to avoid the needle from shifting. The puncture needle is connected with a 30ml or 50ml needle tube through a latex tube with a length of 10cm. When the needle tube is full, the assistant will hold latex tube with another vascular clamp and take out the needle tube to discharge the liquid, which can prevent air from entering the chest cavity. Then connect the needle tube with latex tube and continue to attract.
7. Pull out the puncture needle after smoking, cover it with sterile gauze and fix it with adhesive tape. Ask the patient to stay in bed.
7.8 Precautions 1. Before puncture, the operator should personally make chest X-ray fluoroscopy and select the puncture point. The puncture point should not be too high or too low. If it is too high, it will not be easy to discharge pus. If it is too low, the sediment in the abscess cavity can easily block the puncture needle.
2. Patients should choose * * * which is the most comfortable and convenient for the operator to operate, so as to avoid patients with weak health from insisting on the operation due to overwork.
3. Prepare necessary first-aid medicines for emergency treatment in case of accident.
4, preoperative should clarify the purpose and general process of puncture to patients, in order to eliminate their concerns and get cooperation.
5. During puncture, tell the patient not to cough hard, hold his breath and breathe calmly. If the patient has severe pain, dyspnea, cold sweat, palpitation and cough during puncture, the puncture should be stopped immediately.
6. Pay attention to the depth of needle penetration to avoid bleeding and air leakage caused by stabbing the lungs and large blood vessels. Suction should be as thorough as possible every time. After the pus is extracted, you can inject antibiotic solution that has passed the skin test. For the large abscess cavity without bronchopleural fistula, if the pus is sticky, the three-way tube can be connected and the abscess cavity can be washed with antibiotic solution or 2% sodium bicarbonate solution/kloc-0 once a day.
7. The puncture needle should be inserted vertically along the upper edge of the rib, not obliquely upward, so as not to damage the nerves and blood vessels at the lower edge of the rib.
8, pumping liquid. Don't suck the liquid too fast to prevent negative pressure pulmonary edema. For the purpose of diagnosis, 50200ml of liquid is extracted, and for the purpose of decompression, it shall not exceed 800ml for the first time and 1200ml for each time thereafter.
9. Patients should avoid coughing and turning over during puncture, and take codeine in advance if necessary. If there is persistent cough or pleural reaction such as dizziness, chest tightness, pallor, sweating or even syncope during operation, the infusion should be stopped immediately and the puncture needle should be pulled out. Let the patient lie flat, and inject 1: 1000 adrenaline 0.30.5ml subcutaneously if necessary.
10. When it is necessary to inject drugs into the chest cavity, connect the prepared syringe with the liquid medicine after extracting the liquid and inject the liquid medicine.
1 1, severe emphysema, extensive pulmonary bullae, or lesions close to the heart, large vessels and less pleural effusion, so thoracic puncture should be cautious.