Drainage Procedures:

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Tunnelled Pleural Catheter Placement

AKA Tunnelled Chest Tube Placement AKA PleurX placement AKA Aspira Placement

 

how to place a tunneled chest tube / aspira / pleurx

 

this is spec for placement of the aspira catheter

 

typical indication is for malignant recurring pleural effusion

typicaly for end of life management

 

just know that pleurx has more difficult insurance pre auth and whatnot and might be harder on patient financially than other catheters

 

first review prior imaging.  if pt has chest tube in place, ask for them to clamp tube to make asccessing the effusion eaiser.

 

pt position on table varies.  usually supine is ok with access being made post- lat chest, according to AM trynig to access posterior sulcus.

 

image using us / sonosite, use curved transducer, miage between ribs in the posterior sulcus region.  should be infefior enough that the spleen is present on the image.  if not enough fluid, can access aboev one rib.  (can ask KR about this)

 

AM method is to access paralell to long axis of curved probe, going from medial to lateral, and using the 18 gauge trocar needle.

 

set up table, grab gloves, etc.

 

aspira catheter on table

 

18 G trocar needle to table

 

prep and drape pat., remember that tunnel is anterior and pre that area too

mark site, make nick, open up nick with the kellys

 

acccess fluid using 18 gauge trocar neede.  come in parellel to long axis of probe.  should see needle in the pleural space.  

 

remove inner stylet, then place amplatz wire through (consider glidewire maybe easier to insert)

 

under fluiro guidance, track guidewire up to lung apical region to obtin good purchase of catehter.

 

numb up the tunnel exit site and tunnel tract

 

re. the aspira catheter, it has an internal stiffening catheter than is removed after injecting it with saline to "lube" it up.  leave this in place for now

 

attach aspira catheter tot he tunneler.  make a nick at the exit site, open up with the kelly

 

tunnel aspira from exit to the access site.  remove tunneling device

 

serially dilate at the access site and then place the large bore peel away sheath.  

 

then remove inner componenets.  the sheath is valved usually.  can check visually.  then insert the aspira catheter through the sheath.  watch under fluro according to AM, want to tuck this into the same area ast eh wire basically the apical region of the lung

 

re the tip fo the catheter.  there is a proprietary cap thing that goes on teh catheter.  there are two attachemnets int he kit that should be used for removing fluid.  

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US Guided Paracentesis

 

Generally pretty straight forward

 

Use US (Curved transducer) to image the RLQ or LLQ (RLQ preferred, not sure why)

 

basically want to mark a good spot of fluid where there is skin, subcu, and then tons of fluid

 

if smaller pocket of fluid requested for drainge, may need to go real time

 

raise bed up and pull down the side rail***save your back

 

mark spot and prep for procedure

 

use the 6 F safety-centesis kit (easiest to use)

 

prep skin, numb skin.  When numbing make sure to numb deep and numb up the peritoneum.  Do this by giong in and out of the skin multiple times.  remember to go in the right axis (basically perpedicular to the skin)

 

use scalpel to make skin nick.  

 

set up the safety kit.  remove plastic thing, remove the plastic thing at the base thread needle through catheter, check syringe

 

start advancing the device into the abdomen

 

you should feel a distinct pop when you enter peritoneum.  if pts have had serial para, this might have scarred and there mioght be significant pressure when advancing teh system

 

aspirate on syringe.  then SLIDE catheter FORWARD (dont remove the needle portion or "lose the ground you gained - JF"

 

get samples off of the three way stopcock using 25-50 cc syringes

 

when readty to remove bulk fluid, remove stopcock and attach tubing directly to the small catheter.  this allows for better flow acc. to VS

 

remeber the tubing int the safety kit:  throw away the one with the plastic circular thing, use the tubing that has a needle attached to it

 

let pt drain.  check on patient from time to time

 

if slows down or stops, consider adjusting catheter (pulling out slightly) or adjusting pt, laying in decubitus position to assist drainge

 

if remove greater than 5-6 L, consider giving albumin

ALBUMIN ORDERS:

 

25 g, 25% solution (total volume is 100 cc), give IV infusion 100 ml / hour

6-8 g albumin suggested / liter ascites removed

 

For difficult para:

go real time with ultrasound probe

try using yueh catheter-needle system to access pocket of fluid in real time

 

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