IR( interventional radiology)-2

Thoracentesis

Once patients diagnosed with pleural effusion thoracentesis is performed. It is a process in which pleural fluid is drawn out from the pleural spaces. A catheter is inserted or a needle into the chest wall in the 6th 7th or 8th intercostal space on the midaxillary line.

Thoracentesis

32554 Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance
32555 with imaging guidance
32556 Pleural drainage, percutaneous, with the insertion of indwelling catheter; without imaging guidance
32557 with imaging guidance

1. Sample report:

PROCEDURE- US-guided right thoracentesis.

HISTORY- The patient is a 64-year-old referred by Dr Brown for evaluation of the chest for pleural effusion and thoracentesis.DISCUSSION- The risks and benefits of the procedure were discussed before consent was obtained. Ultrasound was used to evaluate the right pleural space for possible effusion. A suitable collection was identified. This area was marked, prepped, and draped using routine sterile technique. 1% lidocaine was used as local anaesthesia. A 5 French Yueh catheter was carefully advanced into the fluid collection. Approximately 700 Ml of right cloudy fluid was removed without difficulty. The catheter was removed and a sterile bandage was applied to the site. The fluid will be sent to the lab for diagnostics as requested. A post-procedural chest x-ray will be obtained. The patient tolerated the procedure well. No immediate complications. The patient left the department in a stable condition. The procedure was performed by Leiana Jagolino, PA-C, under direct physician supervision.

IMPRESSION- The successful US-guided right therapeutic thoracentesis as described above.

2. Sample report:

1.CT guided thoracentesis:

Indication: Right pleural effusion. CT guided thoracentesis was requested. Procedure: Written informed consent was obtained from the patient. With the patient in the left side down decubitus position, CT of the chest was obtained without contrast in order to localize an appropriate drainage approach. There is a small loculated pleural effusion that appears complex involving the posterior, lateral, anterior pleural space. An appropriate skin level marked posteriorly was made. The skin was prepped with Betadine. Following local anesthesia with 1% Xylocaine, 19-gauge Yueh centesis catheter was directed into the pleural space. Only 15-20 cc of fluid could be removed. I suspect this is an organized process with a mixture of pleural fluid and pleural thickening. The patient tolerated the procedure well without apparent complication

3. Sample report:

DISCUSSION- The risks and benefits were discussed before consent was obtained. Ultrasound was used to evaluate the right pleural space for possible effusion. A suitable collection was identified. This area was marked, prepped, and draped using routine sterile technique. A procedural pause was performed. 1% lidocaine was used as local anaesthesia. A 5 needle was carefully advanced into the fluid collection and approximately 650 mL of thin dark yellow fluid was removed without difficulty. The needle was removed and a sterile bandage was applied to the site. The fluid will be sent to the lab for diagnostics as requested.
A post-procedural chest x-ray will be obtained. The patient tolerated the procedure well. No immediate complications. The patient left the ultrasound suite in stable condition.
.
IMPRESSION- Successful US-guided

Paracentesis:

Removal of fluid or acids from the abdomen through a needle or catheter. This can be either diagnostic or therapeutic.

49082 Abdominal paracentesis (diagnostic or therapeutic); without imaging guidance
49083 with imaging guidance

1. Sample Report:

PROCEDURE- Ultrasound-guided diagnostic and therapeutic paracentesis.

DISCUSSION- This patient was referred by Dr Elmers for evaluation of ascites and possible paracentesis. The procedure was explained to the patient. The risk and benefits were discussed before consent was obtained.
The patient's abdomen was scanned using ultrasound guidance and an ascitic fluid collection was identified. A suitable area for paracentesis was then marked prepped and draped in a routine sterile fashion. The skin and peritoneal lining were anesthetized using 1% lidocaine. A 9 French paracentesis catheter was then placed into the fluid collection and approximately 8.0 liters of yellow clear fluid removed and sent for diagnostic studies as requested. The patient tolerated this procedure well and there are no immediate complications. The patient left the ultrasound suite in stable condition.

IMPRESSION- 1. Successful ultrasound-guided diagnostic and therapeutic paracentesis.