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Clinical Summary

Ultrasound is a source of valuable information that can improve the safety of a wide variety of procedures. The same principles of needle localization and guidance apply. Thoracentesis and paracentesis may be performed using these dynamic “real-time” needle imaging techniques. Alternatively, a static approach may be employed by identifying the location of pathologic fluid and a site for needle insertion. The procedure is then performed in the usual fashion without use of the transducer.

Indications

  • Need for thoracentesis or paracentesis.

  • Pleural effusion or ascites

Equipment

  • Convex

  • Linear

Patient Preparation

  • For paracentesis, supine position or supine with the head of bed slightly elevated.

  • For thoracentesis, the seated upright position is preferred. Lateral decubitus positioning or recumbent position with the ipsilateral arm raised behind the head may also be used.

Technique

Paracentesis

  • After positioning patient, ultrasound the abdomen to identify the largest and safest pocket of ascites (Fig. 24.122). The patient may be repositioned to further improve the target.

  • After optimizing the image and the patient’s positioning, the proceduralist may ultrasound throughout the paracentesis (dynamic technique) or mark the ideal target on the patient and then move forward with the procedure in the usual fashion (static technique).

  • The same sterile techniques should be applied with use of ultrasound as per common practice including a sterile probe cover and sterile gel if dynamic imaging is used.

  • Continue the procedure as per common practice.

FIGURE 24.122

Paracentesis: Abdomen, Transverse. Inferior abdomen with significant ascites. (Ultrasound contributor: Eric Wu, MD.)

Thoracentesis

  • After positioning patient, ultrasound the pleural space posteriorly to identify the largest and safest pocket of pleural fluid (Fig. 24.123). The transducer should be held in the long or sagittal plane with the indicator aimed superiorly. The patient may be repositioned to further improve access.

  • After optimizing the image and the patient’s positioning, the proceduralist may ultrasound throughout the paracentesis (dynamic technique) or mark the ideal target on the patient and then move forward with the procedure in the usual fashion (static technique).

  • When choosing a procedure site using a static technique, locate a site that would be safe throughout the respiratory cycle and avoid diaphragmatic injury. The diaphragm and subdiaphragmatic contents can be easily visualized by ultrasound during normal respiration.

  • The same sterile techniques should be applied with use of ultrasound as per common practice including a sterile probe cover and sterile gel if dynamic imaging is used.

  • Continue the procedure as per common practice.

FIGURE 24.123

Thoracentesis: Right Thorax, Sagittal View. Large pleural effusion identified prior to being drained via thoracentesis. (Ultrasound contributor: Craig Sheedy, MD.)

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