Invasive procedure in cancer patient DR. Alireza Abootalebi Assistant Professor Of Emergency Medicine Isfahan Univercity Of Medical Science

Invasive procedures in cancer patient IN THE NAME OF GOD 5/21/2018 Invasive procedures in cancer patient

Thoracentesis

Invasive procedures in cancer patient Thoracentesis DIAGNOSIS OF PLEURAL EFFUSION Clinical Diagnosis: The three most common symptoms related to pleural effusions are : chest pain Cough dyspnea 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient Thoracentesis DIAGNOSIS OF PLEURAL EFFUSION Radiologic Diagnosis: Chest Radiograph: Pleural effusions are usually visible on an upright postero anterior chest radiograph if 200 to 250 mL of fluid is present. A lateral radiograph may reveal an effusion of 50 to 75 mL. 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient Thoracentesis DIAGNOSIS OF PLEURAL EFFUSION Radiologic Diagnosis: CT: CT is more sensitive than plain films in detecting very small effusions and can readily assess the: Extent number and location of loculated pleural effusions 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient Thoracentesis DIAGNOSIS OF PLEURAL EFFUSION Radiologic Diagnosis: Ultrasound: can detect effusions as small as 5 mL. 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient Thoracentesis INDICATIONS: Diagnostic Thoracentesis Therapeutic Thoracentesis 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient Thoracentesis CONTRAINDICATIONS: There are no absolute contraindications to thoracentesis. Recent studies indicate that if performed under real-time US guidance, thoracentesis is safe despite abnormal coagulation parameters. Avoid skin puncture through a site of cellulitis or herpes zoster 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient Thoracentesis PROCEDURE: A standard 16- to 18-gauge intravenous catheter, threeway stopcock, and syringe are still frequently used. 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient Thoracentesis PROCEDURE: Termination of the Procedure: For diagnostic thoracentesis, terminate the procedure after removal of 50 to 100 mL of fluid. For therapeutic thoracentesis, terminate theprocedure on relief of dyspnea or when up to 1500 mL of fluid has been withdrawn. The recommended maximum of 1500 mL is suggested to help avoid symptomatic hypovolemia and the potentially fatal complication of reexpansion pulmonary edema. Terminate the procedure if aspiration of air occurs, which indicates lung puncture or laceration. Finally, a change in patient symptoms, including abdominal pain and worsening shortness of breath, should raise suspicion for a complication and the procedure should be terminated 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient Thoracentesis PROCEDURE: Insertion Site and Patient Position: Upright positioning is the desired technique for draining most pleural effusions. The lowest level recommended is the space between the eighth and the ninth ribs, which is at the eighth intercostal space. Below the eighth intercostal space, the risk for diaphragmatic or hepatic/splenic injury increases. Medial to the midscapular line the neurovascular bundle is located more centrally in the intercostal space, and the risk for neurovascular injury increases. If the patient is too ill to sit upright, perform the procedure with the patient in the lateral decubitus position, the side of the effusion down. Insert the needle at the posterior axillary line in this position. Alternatively, position the patient supine with the head elevated as much as possible. Use the midaxillary line as the point of needle insertion. 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient Thoracentesis PROCEDURE: Anesthesia and Pleural Fluid Localization: Use a 25-guage needle attached to a syringe containing 5 to 10 mL of 1% lidocaine or an equivalent anesthetic. Raise a skin wheal at the upper edge of the rib just below the marked intercostal space. Use the upper edge of the rib to avoid accidental trauma to the neurovascular bundle, which runs along the inferior margin of each rib 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient Thoracentesis PROCEDURE: Anesthesia and Pleural Fluid Localization: With each 1 to 2 mm of needle advancement, aspirate and then infiltrate the subcutaneous tissue and muscle with 1 to 2 mL of anesthetic. While the aspiration-infiltration process is continued, “walk” the needle above the superior edge of the rib and advance it through the intercostal space until the pleural space is entered Aspirate fluid to ensure that the pleural space has been reached. It is important to properly anesthetize the parietal pleura because it contains abundant sensory nerve fibers 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient 5/21/2018 Invasive procedures in cancer patient

Pericardiocentesis

Invasive procedures in cancer patient Pericardiocentesis The pericardium is a two-layered fibroelastic sac surrounding the heart These two layers create the pericardial space,which normally contains 15 to 50 mL of serous fluid 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient DIAGNOSING CARDIAC TAMPONADE: Diagnosis of pericardial effusions requires integration of the: patient’s history, findings on physical examination, and diagnostic testing 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient DIAGNOSING CARDIAC TAMPONADE: Beck’s triad” is a classic description of acute cardiac compression, which includes: Increased CVP, decreased arterial pressure, and muffled heart sounds 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient DIAGNOSING CARDIAC TAMPONADE: Diagnostic Testing Chest Radiography: In patients with chronic pericardial effusions, chest films often demonstrate an enlarged, saclike, “water-bottle” cardiac shadow or pleural effusion 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient DIAGNOSING CARDIAC TAMPONADE: Diagnostic Testing Electrocardiography: The three most commonly described electrocardiographic findings in pericardial effusion are: PR depression, low-voltage QRS complexes, and electrical alternans 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient DIAGNOSING CARDIAC TAMPONADE: Diagnostic Testing Echocardiography: Echocardiography is the best tool for diagnosing pericardial effusion or tamponade 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient Pericardiocentesis OVERVIEW OF TECHNIQUES AND EQUIPMENT If the patient is able to cooperate, elevate the chest 30 to 45 degrees to bring the heart closer to the chest wall If the patient is awake, anesthetize the skin and the proposed route with 1% lidocaine Because the pericardium is extremely sensitive, it should be anesthetized 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient Pericardiocentesis OVERVIEW OF TECHNIQUES AND EQUIPMENT Subxiphoid/Subcostal Approach: Introduce the needle 1 cm inferior to the left xiphocostal angle at a 30-degree angle to the skin Aim toward the left shoulder Recommendations regarding needle trajectory vary widely, including toward the right shoulder, sternal notch, and left shoulder 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient Pericardiocentesis OVERVIEW OF TECHNIQUES AND EQUIPMENT Apical Approach: If the apex cannot be palpated, it typically lies within the area of cardiac dullness, often between the fifth, sixth, or seventh intercostal space, between the midclavicular and midaxillary lines. Introduce the needle 1 cm lateral to and into the intercostal space below the apical heartbeat. Advance the needle over the cephalad border of the rib and aim it toward the right shoulder 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient Pericardiocentesis OVERVIEW OF TECHNIQUES AND EQUIPMENT Parasternal Approach: Introducing the needle 1 cm lateral to the sternal border at the left fifth or sixth intercostal interspace. 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient 5/21/2018 Invasive procedures in cancer patient

Abdominal paracentesis

Abdominal paracentesis Controlled clinical trials in the late 1980s up to the present have restored its reputation by demonstrating the safety and efficacy of large-volume paracentesis (LVP) in adults and children. LVP, or removal of more than 5 L, ameliorates the shortness of breath and early satiety that patients experience. 5/21/2018 Invasive procedures in cancer patient

Abdominal paracentesis Because transfusionrequiring hematoma is so unlikely, even in this population, prophylactic administration of fresh frozen plasma or platelets is not standard, nor mandated Therefore, for patients undergoing repeated therapeutic paracentesis, in the absence of previous problems or obvious clotting issues, obtaining a platelet count and international normalized ratio (INR) before the procedure is not routine. 5/21/2018 Invasive procedures in cancer patient

Abdominal paracentesis Technique: Preliminary Actions: Paracentesis should be performed after the patient has voided. Place the patient in the supine position. 5/21/2018 Invasive procedures in cancer patient

Abdominal paracentesis Technique: Site of Entry: The best site of entrance for repeated paracentesis is determined by the patient’s previous experience In absence of previous experience with the individual patient, two sites are preferred: One site is approximately 2 cm below the umbilicus in the midline The preferred alternative site is in either the right or left lower quadrant, approximately 4 to 5 cm cephalad and medial to the anterior superior iliac spine 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient 5/21/2018 Invasive procedures in cancer patient

Abdominal paracentesis Procedure: Following sterile preparation of the skin, inject local anesthetic at the paracentesis site Plastic sheath cannulas tend to kink and run the risk of being sheared off into the peritoneal cavity, but a steel needle can be left in the abdomen during a therapeutic tap for intervals of an hour or longer without injury 5/21/2018 Invasive procedures in cancer patient

Abdominal paracentesis Procedure: Insert the needle directly perpendicular to the skin at the preferred site . Alternatively, use the “Ztract” method. For this method, pull the skin approximately 2 cm caudad to the deep abdominal wall with the non–needlebearing hand while slowly inserting the paracentesis needle Release the skin when the needle has penetrated the peritoneum and fluid flows. Avoid continuous suction because it may attract bowel or omentum to the end of the paracentesis needle with resultant occlusion. If flow ceases, gently rotate the needle and advance it inward in 1- to 2-mm increments. When fluid removal is complete, remove the needle and place an adhesive bandage over the puncture site. If there is persistent leakage of fluid, a pressure bandage may be required. 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient 5/21/2018 Invasive procedures in cancer patient

Abdominal paracentesis Volume of Fluid Removed: The best guide to the volume of fluid to be removed for recurrent ascites is based on the patient’s previous experience Up to 5 or 6 L is routine and well tolerated, and for therapeutic purposes, at least this volume should be removed. Patients seen in the ED are probably less compliant with outpatient regimens and seek care only when in extremis. Hence, their ascites is likely to be much more voluminous than in those treated regularly. In general, the paracentesis volume consists of as much fluid as can be removed without excessive manipulation of the patient. Up to 10 to 12 L may be removed safely in most patients with chronic ascites For first-time paracentesis and for diagnostic purposes, 200 to 500 mL is usually sufficient, but more can be drained if it flows easily. 5/21/2018 Invasive procedures in cancer patient

Abdominal paracentesis Volume of Fluid Removed: The authors suggest not using IV albumin after taps of less than 5 L. We suggest that it may be used (6 to 8 g of albumin per liter of fluid removed, or 50 g) when more than 6 to 8 L is removed. 5/21/2018 Invasive procedures in cancer patient

Invasive procedures in cancer patient THE END 5/21/2018 Invasive procedures in cancer patient