A thoracentesis is a surgical puncture of the chest wall to aspirate fluid or air from the pleural cavity. A pleural effusion is an abnormal accumulation of fluid in the pleural space. This protocol covers the task of aspiration of fluid from the pleural cavity by a Nurse Practitioner (NP).

Learning Sequence Builds Confidence

The learner practices the procedure in the ‘guided mode’ (ghosted hints, narrative from tutor) as often as they like. 

When the learner is confident that they can accurately demonstrate the procedure without error, the learner plays the level in the ‘expert mode’ (no hints or coaching narration) - which they can repeat as often as they wish. 

Finally, when the learner is confident that they have mastered the procedure - they take a one-time ‘exam’ attempt which results in their grade for that procedure.

Features

Guided Mode - ghosted hints show step-by-step positions, learner can 'see through' the patient to verify placement.

Oculus Quest Hand Tracking - learner uses natural hand movements to interact (no need to memorize buttons & controls).

Oculus Quest Affordability & Ease of Use - next generation game development processes allow the untethered, mobile VR to present effective visual and interaction fidelity at 1/4 of the cost of desktop VR.

Physiology Engine - real-world patient & case data informs the simulation.

Feedback - Cloud-based enterprise incorporates real-time data acquisition that allows learner to track progress and mastery, and provides detailed insights for debrief with faculty.

Support - Enterprise incorporates Knowledge Base (with tutorial videos & FAQ) - combined with help desk support staff for learners and staff.

Objectives

Identify anatomic structures with ultrasound to avoid complications from thoracentesis.
Demonstrate informed consent for a thoracentesis procedure.
Perform a diagnostic and therapeutic thoracentesis procedure.
Incorporate feedback to improve thoracentesis performance.
Interpret laboratory values to diagnose the etiology of pleural effusion.

Thoracentesis Checklist

1. Wash hands and don personal protective equipment.
2. Check platelet count and/or presence of coagulopathy. Consult with attending physician if platelet count is <50,000, or there is a known coagulopathy as to whether platelet transfusion or other intervention is needed prior to the procedure.
3. Check patient history for hypersensitivity to the local anesthetic.
4. Position patient in the sitting position with arms and head resting supported on a bedside adjustable table. If unable to sit, the patient should lie at the edge of the bed on the affected side with the ipsilateral arm over the head and the midaxillary line accessible for the insertion of the needle. Elevating the head of the bed to 30 degrees may help.
5. The usual site for insertion of the thoracentesis needle is the posteriolateral aspect of the back over the diaphragm, but under the fluid level. Confirm site by counting the ribs based on chest x-ray and percussing out the fluid level. Mark the top of the dullness by washable ink mark or indenting the skin.
6. Select the thoracentesis site in an interspace below the point of dullness to percussion in the midposterior line (posterior insertion) or midaxillary line (lateral insertion).
7. Sterile technique should be used including gloves, Chlorhexadine prep and drape
8. Anesthetize the skin over the insertion site with 1% lidocaine using the 5 ml syringe with 25 or 27-gauge needle. Next anesthetize the superior surface of the rib and the pleura. The needle is inserted over the top of rib (superior margin) to avoid the intercostals nerves and blood vessels that run on the underside of the rib (the intercostals nerve and the blood supply are located near the inferior margin).
9. Use a hemostat to measure the same depth on the thoracentesis needle or angiocath as the first needle. While exerting steady pressure on the patient’s back with the nondominant hand, use a hemostat to measure the 15- to 18- gauge thoracentesis needle to the same depth as the first needle. While exerting steady pressure on the patient’s back with the nondominant hand, insert the needle through the anesthetized area with the thoracentesis needle. Advance the needle until it encounters the superior aspect of the rib. Continue advancing the needle over the top of the rib and through the pleura, maintaining constant gentle suction on the syringe. Make sure you march over the top of the rib to avoid the neurovascular bundle that runs below the rib.
10. Attach the three way stopcock and tubing, and aspirate the amount needed. Turn the stopcock and evacuate the fluid through the tubing.
11. Remove the necessary amount of pleural fluid (usually 100 mL for diagnostic studies) but generally not remove more than 1500 mL of fluid at any one time because of increased risk of pleural edema or hypotension. A pneumothorax from needle laceration of the visceral pleura is more likely to occur if an effusion is completely drained.
12. Cover the insertion site with a sterile occlusive dressing.
13. Obtain an upright portable (expiratory) chest x-ray to evaluate the fluid level and to rule out pneumothorax.