Tindakan torakosentesis

Indikasi torakosentesis adalah (2) :

1. efusi parapneumonik yang mengalami komplikasi atau empiema

2. mengurangi rasa sesak nafas

3. evaluasi dasar penyakit paru kronik

Pada tindakan torakosentesis perlu diperhatikan :

-          cara aspirasi cairan dengan terarah jarum yang miring. 

-          dikeluarkan cairan EP sampai 1000- 1200 ml sekali ambil

-          lakukan monitoring dengan oxymeter agar saturasi >90%. Pasca torakosenstesis dapat

hipoksemia terjadi akibat reaksi paradoksal pada perluasan area dengan rasio V/Q yang

rendah, dan edem paru unilateral akibat reekpansi paru.

-          dapat dilakukan aspirasi ulangan bila ada indikasi, namun bila selalu terbentuk cairan

kembali perlu dipertimbangkan tindakan pleurodesis.

Thoracentesis 

Overview

Background

Thoracentesis (thoracocentesis) is a core procedural skill for hospitalists, critical care physicians, and emergency physicians. With proper training in both thoracentesis itself and the use of bedside ultrasonography, providers can perform this procedure safely and successfully.[1, 2] Before the procedure, bedside ultrasonography can be used to determine the presence and size of pleural effusions and to look for loculations. During the procedure, it can be used in real time to facilitate anesthesia and then guide needle placement.

Indications

Thoracentesis is indicated for the symptomatic treatment of large pleural effusions (see the images below) or for treatment of empyemas. It is also indicated for pleural effusions of any size that require diagnostic analysis.[3]

Image of a 48-year-old woman with cancer and large left pleural effusion (2.5 liters were removed). The patient was tachypneic, hypoxic, and reported pleuritic chest pain.

Chest radiograph after thoracentesis of the cancer patient shown above.

Transudative effusions result from decreased plasma oncotic pressures and increased hydrostatic pressures. Heart failure is by far the most common cause, followed by liver cirrhosis and nephrotic syndrome.

Exudative effusions result from local destructive or surgical processes that cause increased capillary permeability and subsequent exudation of intravascular components into potential spaces. Causes are manifold and include pneumonia, empyema, cancer, pulmonary embolism, and numerous infectious etiologies.

Contraindications

There are no absolute contraindications for thoracentesis. Relative contraindications include the following:

Uncorrected bleeding diathesis Chest wall cellulitis at the site of puncture

Periprocedural Care

Patient Education/Informed Consent

Before thoracentesis, it is important to pay attention to the consent process and provide a focused set of risks and complications, so that the patient is not surprised if he or she experiences adverse effects.[4]

Consent should be obtained from the patient or family member. The reason the procedure is being performed (suspected diagnosis); the risk, benefits, and alternatives of the procedure; the risks and benefits of the alternative procedure; and the risk and benefits of not undergoing the procedure. Allow the patient the opportunity to ask any questions and address any concerns they may have. Make sure that they have an understanding about the procedure so they can make an informed decision.

The patient should be counseled about the risks of pneumothorax, hemothorax, lung laceration, infection, empyema, damage to the intercostals, or internal mammary vessels, diaphragmatic injury, puncture of the liver or spleen, damage to other abdominal organs, abdominal hemorrhage, reexpansion pulmonary edema, air embolism, cough, pain, and catheter fragment left in the pleural space.

Discuss how these risks can be avoided or prevented (eg, proper positioning, ensuring that the patient remains as still as possible during the procedure, adequate analgesia).

Equipment

Several commercially available medical devices are specifically designed for performing thoracentesis. Such devices include the following:

Arrow-Clarke Thoracentesis Device (Teleflex Medical, Research Triangle Park, NC) Argyle Turkel Safety Thoracentesis System (Covidien, Mansfield, MA)

Critical Care Thoracentesis Set (Cook Medical, Bloomington, IN)

If a commercial use-specific device is not available, all of the necessary equipment can be obtained from the supplies located in most inpatient settings, critical care units (CCUs), or emergency departments (EDs).

Thoracentesis device - This typically consists of an 8-French catheter over an 18-gauge, 7.5-in. (19-cm) needle with a 3-way stopcock and, ideally, a self-sealing valve

Self-assembled device, if a thoracentesis device is unavailable - Options include using an 18-gauge needle or a 12-gauge intravenous (IV) catheter connected to a 60-mL syringe and then to a stopcock after the needle is removed from the 60-mL syringe

Injection needle – 22 gauge, 1.5 in. (3.81 cm)

Injection needle – 25 gauge, 1 in. (2.54 cm)

Luer-Lok syringe - 10 mL

Luer-Lok syringe - 5 mL

Luer-Lok syringe - 60 mL

Tubing set with aspiration/discharge device

Antiseptic - Chlorhexidine solution [Hibiclens] is preferred

Lidocaine - 1% or 2% solution, 10-mL ampule

Specimen cap for 60-mL syringe

Specimen vials or blood tubes

Drainage bag or vacuum bottle

Drape - 24 × 30 in., with 4-in. fenestration with adhesive strip

Sterile towels

Scalpel - No. 11 blade

Adhesive dressing - 7.6 × 2.5 cm

Gauze pad(s) - 4 × 4 in.

Patient Preparation

Patient preparation includes adequate anesthesia and proper positioning.

Anesthesia

In addition to local anesthesia, mild sedation may also be considered. IV midazolam or lorazepam can attenuate the anxiety that may be associated with any invasive procedure. Analgesia is critically important, in that pain is the most common complication of thoracentesis. Local anesthesia is achieved with generous local infiltration of lidocaine.

The skin, subcutaneous tissue, rib periosteum, intercostal muscle, and parietal pleura should all be well infiltrated with local anesthetic. It is particularly important to anesthetize the deep part of the intercostal muscle and the parietal pleura because puncture of these tissues generates the most pain. Pleural fluid is often obtained via aspiration during anesthetic infiltration of these deeper structures; this helps confirm proper needle location.

Positioning

Patients who are alert and cooperative are most comfortable in a seated position (see the image below), leaning slightly forward and resting the head on the arms or hands or on a pillow, which is placed on an adjustable bedside table. This position facilitates access to the posterior axillary space, which is the most dependent part of the thorax. Unstable patients and those who are unable to sit up may be supine for the procedure.

One option for proper positioning of patient. Easy access to the 7-9 rib space along the posterior axillary line.

The patient is moved to the extreme side of the bed, the ipsilateral hand is placed behind the head, and a towel roll is placed under the contralateral shoulder. This measure facilitates dependent drainage and provides good access to the posterior axillary space.

Technique

Approach Considerations

Proper personnel resources should be ensured, appropriate equipment collected, and diagnostic laboratory studies preordered, as necessary.

The clinician should become comfortable with the equipment available at the facility. If necessary, an unused kit or one from an aborted procedure may be opened to permit evaluation of the components. The clinician should likewise become comfortable with the ultrasound machine and learn how to adjust key functions such as depth and overall gain.

Anxiolysis should be considered and good local analgesia provided. Thoracentesis can be fraught with patient anxiety, and pain is the most common complication. If mild sedation is being considered, intravenous (IV) medications should be administered to the patient in advance.

The patient should be positioned appropriately. Thoracentesis can be performed with the patient sitting upright and leaning over a Mayo stand or with the patient supine (via an axillary approach).

Thoracentesis (Thoracocentesis)

Thoracentesis is performed as follows.[5]

Bedside ultrasonography

After the patient has been positioned, ultrasonography is performed to confirm the pleural effusion, assess its size, look for loculations, and determine the optimal puncture site. Either a curvilinear transducer (2-5 MHz) or a high-frequency linear transducer (7.5-1 MHz) may be used (see the image below). The diaphragm is brightly echogenic and should be clearly identified. Its exact location throughout the respiratory cycle should be determined. It is important to select a rib interspace into which the diaphragm does not rise up at end-exhalation.

Ultrasound image using curvilinear probe. Image shows chest wall and large volume of pleural fluid.

Motion-mode (M-mode) ultrasonography can also be used to determine the depth of the lung and the amount of fluid between the chest wall and the visceral pleura (see the image below). Freely floating lung can be seen as wavelike undulations on the M-mode tracing.

Ultrasound image in M-mode showing sinusoidal wave pattern. This is created by the lung moving within the large pleural effusion during respiration. The depth of the lung and the amount of fluid between the parietal pleura (adherent to the chest wall) and visceral pleura (adherent to lung tissue) are easily measured with ultrasonography.

Bedside ultrasonography is a useful guide for thoracentesis: It can determine the optimal puncture site, improve the administration of local anesthetics, and, most important, minimize the complications of the procedure.[2]

The optimal puncture site may be determined by searching for the largest pocket of fluid superficial to the lung and by identifying the respiratory path of the diaphragm (see the video below). Traditionally, this is between the 7th and 9th rib spaces and between the posterior axillary line and the midline. Bedside ultrasonography can confirm the optimal puncture site, which is then marked.

Video clip of ultrasound using the linear probe. Image demonstrates 2 ribs with their associated acoustic shadows, rib interspace, pleural fluid, and the presence of the diaphragm rising up into this rib interspace.

Preparation of puncture site

Standard aseptic technique is used for the remaining steps of the procedure. Sterile probe covers are available and should be used if thoracentesis is performed under real-time ultrasonographic guidance.

A wide area is cleaned with an antiseptic bacteriostatic solution.[6] Chlorhexidine solution is preferred for preparing the skin (see the image below); it dries faster and is far more effective than povidone-iodine solution.

Application of chlorhexidine solution.

A sterile drape is placed over the puncture site (see the first image below), and sterile towels are used to establish a large sterile field within which to work (see the second image below).

Sterile drape with fenestration and adhesive strip placed over puncture site,

with sterile towels draping a large work area. Sterile towels on the bed, creating a large sterile work space.

If the patient has loose skin or significant subcutaneous tissue, the puncture site can be optimized by using 3-in. tape to pull the skin or subcutaneous tissue out of the way before marking the spot and cleaning the puncture site.

The skin, subcutaneous tissue, rib periosteum, intercostal muscles, and parietal pleura should be well infiltrated with anesthetic (lidocaine 1-2%) (see the image below). Infiltration can also be guided by real-time ultrasonography using a high-frequency linear transducer (7.5-10 MHz).

Administering anesthesia to the skin, subcutaneous tissue, rib periosteum, intercostal muscle, and parietal pleura.

Insertion of device or catheter and drainage of effusion

If a commercially available device or a large intravenous catheter is being used, the skin should be nicked with a No. 11 scalpel blade to reduce drag as the catheter is advanced through the skin (see the image below).

Nicking the skin with scalpel to reduce skin drag as the catheter is advanced through the skin.

With aspiration initiated, the device is advanced over the superior aspect of the rib until pleural fluid is obtained (see the image below). The neurovascular bundle is located at the inferior border of the rib and should be avoided.

Advancing the device over the superior aspect of the rib.

Most commercial devices have a marker at 5 cm (see the image below). At this depth, the hemithorax is usually entered, and the needle need not need be advanced any further.

The 5-cm mark is at the level of the skin.

The catheter is then fed over the needle introducer (see the first image below). In most cases, it can be fed all the way to the hub (see the second image below).

Feeding the catheter over the needle introducer.

The catheter is fed all the way to the hub.

With either a syringe pump or a vacuum bottle, the pleural effusion is drained until the desired volume has been removed for symptomatic relief or diagnostic analysis (see the image below).

Use the manual syringe pump method or a vacuum bottle. The syringe pump method (shown here) is more labor intensive and can cause thumb neurapraxia in the operator.

Completion of procedure

The catheter or needle is carefully removed, and the wound is dressed. If there is any doubt, pleural fluid should be sent for diagnostic analysis (see below); in practice, diagnostic analysis is almost always necessary. The patient is repositioned as appropriate for his or her comfort and respiratory status.

Finally, a procedure note is written, commenting specifically on the descriptive characteristics of the pleural fluid.

Diagnostic Analysis of Pleural Fluid

Pleural fluid is labeled and sent for diagnostic analysis. If the effusion is small and contains a large amount of blood, the fluid should be placed in a blood tube with anticoagulant so that it does not clot. The following laboratory tests should be requested:

pH level Gram stain, culture

Cell count and differential

Glucose level, protein levels, and lactic acid dehydrogenase (LDH) level

Cytology

Creatinine level if urinothorax is suspected (eg, after an abdominal or pelvic procedure)

Amylase level if esophageal perforation or pancreatitis is suspected

Triglyceride levels if chylothorax is suspected (eg, after coronary artery bypass graft [CABG], especially if the inferior mesenteric artery [IMA] was used; milky appearance is not sensitive)

Exudative pleural fluid can be distinguished from transudative pleural fluid by looking for the following characteristics (exudates have 1 or more of these characteristics, whereas transudates have none):

Fluid/serum LDH ratio ≥ 0.6 Fluid/serum protein ratio ≥ 0.5

Fluid LDH level within the upper two thirds of the normal serum LDH level

Complications of Procedure

Complication rates for thoracentesis performed by experienced clinicians are not available. However, data on complications that develop after thoracentesis performed by residents learning the procedure are available.[7, 1]

Major complications include the following:

Pneumothorax (11%[8] ) Hemothorax (0.8%)

Laceration of the liver or spleen (0.8%)

Diaphragmatic injury

Empyema

Tumor seeding

Minor complications include the following:

Pain (22%) Dry tap (13%)

Cough (11%)

Subcutaneous hematoma (2%)

Subcutaneous seroma (0.8%)

Vasovagal syncope

o Perubahan Patologi atau Patofisiologi

Tulang bersifat terlalu rapuh, namun cukup mempunyai kekuatan dan daya tahan

pegas untuk menahan tekanan, tulang yang mengalami fraktur, biasanya diikuti kerusakan

jaringan sekitarnya. Fraktur ini suatu permasalahan yang kompleks karena pada fraktur

tersebut tidak dilukai luka terbuka, sehingga dalam mereposisi fraktur tersebut perlu

pertimbangan dengan fiksasi yang baik agar tidak timbul komplikasi selama reposisi.

Penggunaan fiksasi yang tepat yaitu dengan internal fiksasi jenis plate and screw. Dilakukan

operasi terhadap tulang ini bertujuan mengembalikan posisi tulang yang patah ke normal

atau posisi tulang sudah dalam keadaan sejajar sehingga akan terjadi proses penyambungan

tulang, yang menurut (Appley, Ronald, 1995). Stadium penyembuhan fraktur melalui

beberapa tahap antara lain dapat dilihat pada tabel:

Tabel 2.5 Tahap-tahap atau proses penyembuhan tulang

Hematoma Proliferasi Kalsifikasi Konsolidasi Remodeling

Tulang Tulang patah

mengenai

pembuluh

darah

Terbentuk

hematoma di

sekitar

pepatahan

Hematoma

dibentuk

jaringan lunak

di sekitarnya

Permukaan

tulang yang

patah tidak

mendapatkan

supplay

Berlangsung

selama24 jam

setelah terjadi

perpatahan

Sel-sel

periosteum dan

endosteum paling

menonjol pada

tahap proliferasi

Proliferasi dari

sel-sel dalam

periosteum yang

menutupi fraktur,

sel-sel ini

merupakan

tumbuhnya

osteoblast

Akan melepaskan

unsur-unsur

intraseluler dan

kemudian

menjadi fragmen

lain

Berlangsung

selama 3-4 hari

Jaringan

seluler yang

keluar dari

masing-masing

fragmen yang

sudah matang

Sel-sel

memberi

perlengkapan

untuk

osteoblast.

Condoblast

membentuk

callus yang

belum masak

dan

membentuk

jendolan.

Adanya

rigiditas pada

fraktur

Berlangsung

selama 6-12

minggu

Callus yang

belum masak

akan

membentuk

callus

Berlangsung

bertahap dan

berubah-ubah

Adanya

aktivitas

osteoblast

menjadi tulang

lebih kuat dan

masa

strukturnya

berlapis-lapis

Berlangsung

setelah 12-14

minggu

Tulang

menyambung

atau

membentuk

baik dari luar

maupun dari

dalam canalis

medularis.

Osteoblast

mengabsorbsi

pembentukan

tulang yang

lebih.

Berlangsung

selama 24

minggu

sampai 1

tahun

Tabel 2.6 Tahap-tahap atau proses penyembuhan otot

Peradangan Proliferasi Remodeling

Otot Radang adalah

mekanisme

pertahanan diri pada

otot yang terluka.

Reaksi radang

menyebabkan

musnahnya agen yang

membahayakan dan

mencegah penyebaran

Terjadinya perbaikan jaringan

epitelium dan jaringan penghubung

(connectifity).

Epitelium adalah lapisan yang

membentuk epidemis kulit dan

lapisan permukan mukosa.

Jaringan penghubung adalah

jaringan yang terdapat pada jaringan

ekstra selular.

Terjadi

pembentukan matrik

jaringan connective

dan sebagai fase

penguatan jaringan

parut, jaringan

kolagen dilepaskan

oleh fibriosis serta

jaringan connective

yang luas.

Radang juga

menyebabkan jaringan

yang cidera diperbaiki

atau diganti yang

baru.

Tanda-tanda radang:

Bengkak (tumor),

berwarna kemerahan

(rubon), panas (kalor),

gangguan gerak

(fungsiolesi)

Fibriobrasi akan berguna pada

daerah yang mengalami peradangan

dengan membentuk fibrin, lalu akan

membentuk jaringan parut yang

akan menyokong tensil strength

untuk perbaikan.

Disaat yang bersamaan sel endotel

baru berkembang.

Setelah berlangsung selama 7 hari

degenerasi protein miofibril akan

berlangsung secara perlahan-lahan

yang diikuti dengan serangan

phagocytic.

Sel-sel otot yang mati akan

berpindah.

masih bersifat

lunak.

Organisasi sejajar

masih terbentuk

pada permukaan

luka sehingga akan

memelihara tensil

strength.

Namun kekuatan

maximum dari

jaringan parut hanya

70% dari jaringan

normal.

Tabel 2.7 Tahap-tahap atau proses penyembuhan kulit

Radang Poliferasi Cicatrik

Kulit Pada 24 jam pertama akan

mengalami reaksi radang

yang mendadak.

Hal-hal di bawah merupakan

kejadian hislogik yang terjadi

48 jam pertama

penyembuhan luka.

8 jam, meluasnya area

jaringan yang mengalami

nekrosis pada kedua sisi

sayatan.

16 jam epitelium yang

terletak antara jaringan yang

masih hidup dengan jaringan

nekrotik mengalami

penebalan 24 jam ke 2, epitel

yang berasal dari jaringan

epitel yang masih hidup dan

berinvasi mendekatkan ke 2

ujungnya.

Setelah 3-9 hari epitel akan

menutup kembali keratin dan

meluasnya permukaan luka

yang berkembang.

Epidermis yang berhubungan

dengan selokan berkurang

karena mutasi atau

perpindahan, dari fibrobast

dan terisi oleh jaringan

granulasi, jaringan granulasi

tersusun dari epitelialossel.

Fibroblast yang melepaskan

collagen yang digunakan

untuk pembentukan bekas

luka dan kapiler membantu

terbentuknya jaringan parut

yang kemerahan.

Jarinan garnulasi akan

terbentuk berdasarkan

terjadinya luka.

Sebelum permukaan epitel

Merupakan fase

pembentukan

jaringan parut

permanen

jaringan parut

tersebut akan

berkonstruksi dan

pembuluh darah

yang terdapat

didalamnya akan

dilenyapkan,

sehingga jaringan

parut berubah

putih, colagen

menjadi kuat,

bekas luka tidak

bisa dihilangkan.

Berlangsung

beberapa minggu

sampai beberapa

40 sampai 48 jam kedua,

epitel tersebut akan bertemu

dan membuang nekrotik dari

lapisan jaringan yang

keraktiosa, lalu keduanya

bergabung dan menyatu di

bawah luka dengan

memutuskan hubungan pada

luka yang bertujuan

mengeluarkan perompeng.

tersebut terbentuk, jaringan

granulasi yang baru

bergabung dengan fibroblast

dan kapiler akan berangsur

pulih.

Lalu secara berangsur-angsur

akan terjadi konstruksi pada

luka dipermukaan epitelium.

bulan

Tabel 2.8 Tahap-tahap atau proses penyembuhan jaringan lunak

Jaringan lunak

Peradangan Siklus perlukaan menyebabkan reaksi dari jaringan mengakibatkan

merusak sel karena trauma, infeksi, ischemia, sekunder atau agen fisik.

Reaksi radang untuk memulai proses healing, tetapi proses healing tidak

terjadi sampai reaksi peradangan reda.

Dengan dimulainya respon peradangan maka siklus perlukaan telah

terlihat

Dalam persendian dan struktur peri artikuler reaksi jaringan mengarah

kepada reaksi yang berlebihan, synovial menjadi hipertensi, kadang

hematrosis dan akhirnya proses ini tidak terlewati akan terjadi

degenerasi.

Jaringan lunak lainnya reaksi salah satunya adalah oedem dan kadang

disertai hemorage.

Perubahan ini membuat peradangan mengarah pada nyeri dan protektif

spastik

Pembekuan Dengan adanya luka yang diikuti pendarahan dan vasokontriksi pada

pembuluh darah.

Mekanisme pembekuan, biasanya selesai selama 5 menit tetapi dapat

memakan 24 sampai 38 jam

Tromboplastin, tromboplastin (plasma protein) menjadi trombin dibantu

enzim trombo plastin dan lonca trombin serta fibrinogen bergabung

membentuk fibrin yang akhirnya fibrin bersama platelest menjadi bekuan

darah.

Reconstitution

of communty

Dengan istirahat dan terapi yang adekuat akan mempercepat penanganan

sehingga respon penyembuhan dapat terjadi.

Berpengaruh terhadap perbaikan, regenerasi, hypertrophy, pengurangan

nyeri, pengembalian ROM, menjadikan jaringan normal, perbaikan

kekuatan, perbaikan pola gerakan normal

Tabel 2.9 Tahap-tahap atau proses penyembuhan syaraf

Syaraf Jaringan lunak

Proses penyembuhan neufibril bagian proksimal cidera menuju distal.

Pembentukan selubung myelin dari selubung chutan terus berkembang,

neurofibril tumbuh di sekeliling protoplasma.

Pertumbuhan ini terjadi 1 mm/hari.

Bila selubung myelin sembuh sempurna maka fungsi syaraf akan pulih.

Tanda awalnya bila disentuh akan terasa nyeri pada syaraf.

Proses perbaikan syaraf tergantung dari:

Panjang luas yang mengalami cidera, teknik pembedahan, lama waktu

penyembuhan

Bagaimana fraktur terjadi?

Tulang bersifat relatif rapuh, namun cukup mempunyai kekuatan dan gaya pegas untuk

menahan tekanan. Fraktur dapat terjadi akibat: 1) peristiwa trauma tunggal, 2) Tekanan yang

berulang-ulang, atau 3) kelemahan abnormal pada tulang (fraktur patologik).

Fraktur akibat peristiwa trauma

Sebagian besar fraktur disebabkan oleh kekuatan yang tiba-tiba dan berlebihan, yang dapat

berupa pemukulan, pemuntiran atau penarikan.

Bila terkena kekuatan langsung tulang dapat patah pada tempat yang terkena, jaringan lunak

juga pasti rusak. Pemukuan (pukuran sementara) biasanya menyebabkan fraktur melintang dan

kerusakan pada kulit diatasnya; penghancuran kemungkinan akan menyebabkan fraktur

kominutif disertai kerusakan jaringan lunak yang luas (Appley, 1995).

Bila terkena kekuatan yang tidak langsung tulang dapat mengalami fraktur pada tempat tang

jauh dari tempat yang terkena kekuatan itu; kerusakan jaringan lunak di tempat fraktur mungkin

tidak ada (Appley, 1995).

Kekuatan dapat berup: 1) pemuntiran, yang menyebabkan fraktur spinal; 2) penekukan, yang

menyebabkan fraktur melintang; 3) penekukan dan penekanan, yang mengakibatkan fraktur

yang sebagian melintang tetapi disertai fragmen kupu-kupu berbentuk segitiga yang terpisah; (4)

kombinasi dari pemuntiran, penekukan dan penekanan, yang menyebabkan fraktur oblik

pendek, atau 5) penarikan, dimana tendon atau ligament benar-benar menarik tulang sampai

terpisah (Appley, 1995).