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

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

3. Thoracentesis

4. 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
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Invasive procedures in cancer patient

5. 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.
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Invasive procedures in cancer patient

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Invasive procedures in cancer patient

7. Invasive procedures in cancer patient
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Invasive procedures in cancer patient

8. 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
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Invasive procedures in cancer patient

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Invasive procedures in cancer patient

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

11. Invasive procedures in cancer patient
Thoracentesis
INDICATIONS:
Diagnostic Thoracentesis
Therapeutic Thoracentesis
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Invasive procedures in cancer patient

12. 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
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Invasive procedures in cancer patient

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

14. 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
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Invasive procedures in cancer patient

15. 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.
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Invasive procedures in cancer patient

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Invasive procedures in cancer patient

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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
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Invasive procedures in cancer patient

18. 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
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Invasive procedures in cancer patient

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Invasive procedures in cancer patient

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Invasive procedures in cancer patient

21. Pericardiocentesis

22. 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
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Invasive procedures in cancer patient

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

24. 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
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Invasive procedures in cancer patient

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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
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Invasive procedures in cancer patient

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Invasive procedures in cancer patient

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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
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Invasive procedures in cancer patient

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

31. 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
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Invasive procedures in cancer patient

32. 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
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Invasive procedures in cancer patient

33. 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
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Invasive procedures in cancer patient

34. 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.
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Invasive procedures in cancer patient

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Invasive procedures in cancer patient

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Invasive procedures in cancer patient

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Invasive procedures in cancer patient

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Invasive procedures in cancer patient

39. Abdominal paracentesis

40. 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.
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Invasive procedures in cancer patient

41. 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.
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Invasive procedures in cancer patient

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

43. 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
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Invasive procedures in cancer patient

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Invasive procedures in cancer patient

45. 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
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Invasive procedures in cancer patient

46. 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.
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Invasive procedures in cancer patient

49. 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.
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Invasive procedures in cancer patient

50. 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.
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THE END
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Invasive procedures in cancer patient