Inpatient
- The GPU residents/staff will order diagnostic/therapeutic thoracentesis through EPIC. Arrangements have been made through EPIC, so that every time a thoracentesis order is typed, there will be 2 options: Thoracentesis-Pulmonary and Thoracentesis (radiology).
- Once Thoracentesis-Pulmonary is selected, the name of the patient will go to a workqueue in the bronchoscopy suite.
- If the order is entered before 2pm, thoracentesis should happen the same day. If it is after 2pm, the bronchoscopist will decide if it can happen the following day.
- Once the thoracentesis is performed, the patient will return to his/her room with recommendations given by the bronchoscopist.
- If further procedures are needed (diagnostic medical thoracoscopy, indwelling pleural catheters, chest tube), the Interventional Pulmonology (IP) Team should be consulted.
- If patient needs surgical procedures, the IP Team will discuss it with Thoracic surgery.
- Ideally, a patient with a recurrent pleural effusion of unknown etiology should undergo a diagnostic thoracoscopy after the second thoracentesis (at the latest), or after the first thoracentesis if one of the following criteria is met:
- Lymphocytic effusion (>50% of lymphocytes)
- High pre-test probability of malignancy and negative cytology
- h/o lung cancer (even if it is in remission)
THORACENTESIS: GUIDELINES FOR THE PROCEDURE
- Inpatient Consult
- Inpatient consult will be done by the Bronchoscopy Fellow or Bronchoscopy Staff.
- A note in Epic will be entered as part of the consult
- The fellow/staff WILL communicate with the IPD consult team right after completing the thoracentesis, so that the IPD consult team will follow the patient/results
- Workflow
- Patient arrives to Bronchoscopy suite
- Evaluation by the nurse
- Evaluation by bronchoscopy fellow/staff: includes consultation, physical exam, consent (in the same way as a Miniconsult)
- Patient MUST have a CXR imaging prior to thoracentesis (within the last 5-7 days at least)
- Thoracentesis to be performed in Bronchoscopy Room #3
- Nurse to evaluate the patient after the procedure
- Nurse to discharge patient
- Procedure: Guidelines
- Every thoracentesis MUST be done under Ultrasound guidance
- The amount to be drained: will depend on the staff, but recommend to drain as much as possible
- Fluid analysis: the following tests are to be ordered on EVERY DIAGNOSTIC THORACENTESIS, AT LEAST:
- LDH, Protein (pleural fluid and serum)
- Cell count and differential
- Cytology
- Other tests in pleural fluid should be ordered depending on the case (depending on the staff)
- Therapeutic thoracentesis: no need to order analysis in fluid if there is already a diagnosis (will depend on the staff)
- A post-thoracentesis CXR has to be done in patients to assess for lung entrapment.