Puncture

Puncture, in medical terms refers to puncture of a body cavity, joint, organ or a pathological structure for diagnostic or therapeutic purposes.

Puncture division

 * 1) According to purpose:
 * 2) Diagnostic – sampling the body fluid (transudate, exsudate – most often pus, blood) or tissue sample for histological, cytological, microbial (culture) or biochemical examination.
 * 3) Therapeutic:
 * 4) evacuation of the fluid or gas (elimination of pressure – hemopericardium, hemotorax, PNO, ascites, etc.),
 * 5) drug instillation,
 * 6) drainage, or lavage followed by puncture.
 * 7) According to design:
 * 8) straight,
 * 9) stepped (specific absces, joint) – protection against infections.
 * 10) According to the knowledge of the punctured unit:
 * 11) targetted,
 * 12) probatory.

Puncture units

 * Natural cavities (pleural, pericardial, peritoneal, joints, bladder, paranasal sinuses, etc.).
 * Parenchymatous organs (liver, kidneys, spleen, etc.) and bone marrow (aspiration biopsy or trepanobiopsy).
 * Pathological formations (cyst, absces, tumor, hematoma, etc.).

Administration of the puncture

 * Superficial formations may be punctured blindly;
 * deep-seated formations and organs, punctures are performed under the control of ultrasound or CT;
 * it is necessary to follow rules of asepsis and use appropriate local anesthetics.
 * Puncture needles:
 * vary in diameter and length;
 * some contain mandrel, so they do not clog (very wide mandrel needles are called trocars);
 * recently used Chiba-needle 15 to 20 cm in length, from 0,5 mm in internal diameter, that is soft and flexible and minimizes the risk of injury to surrounding structures.

Complications

 * Complications of abdominal punctures include:
 * bleeding,
 * peritonitis,
 * fistula formation,
 * tumor metastasis to the puncture canal,
 * pneumotorax,
 * pancreatitis in pancreatic punctures.

Puncture of the pleural cavity

 * Based on the indication (gas, liquid) two approaches are used:
 * 1) according to Monaldi – puncture of pneumothorax – in the 2nd or 3rd intercostal space in medioclavicular line, in half-sitting position;
 * 2) according to Bullau – puncure of fluidothorax – in the 6th intercostal space along the anterior axillary line, in sitting position.
 * The puncture can be followed by drainage, possibly performed:
 * 1) by using trocar (modification by Seldinger technique included: needle – guidewire – dilators – drain);
 * 2) blunt dissection by a peanut sponge.

Puncture of a pericardial cavity

 * Through Larrey's left slit - trigonum sternocostale.
 * inserting the needle just to the left of gladiolus at 45° angle – with the tip of the needle directed to the center of the left clavicle.
 * ECG electrode can be attatched to the needle.
 * If the intracardial drug administration is necessary (resuscitation), we puncture the left ventricle obliquely in the 5th intercostal space in the medioclavicular line.

Pucture of peritoneal cavity

 * It is indicated primarily for ascites as a relieving procedure and for puncture examination ;
 * it is performed outside the center of the left umbilicospinal line at the Monro point ;
 * in women, the Douglas space is punctured through the posterior vaginal arch, transrectal access is possible with an abscess in the Douglas space ;
 * diagnostic peritoneal lavage (ultrasound of the abdomen is prefered nowadays) in traumas is performed by punctures in all 4 abdominal quadrants.

Bone marrow biopsy

 * 1) Aspiration biopsy – sternal puncture, puncture of the hipbone wing or tibia.
 * 2) Trepanobiopsy – wing of the hipbone;
 * Bone marrow sampling sites are laid superficially, under the skin, hematopoiesis takes place here until old age.

Sternal puncture

 * Performed at body of the sternum at the level of 2nd or 3rd intercostal space in the midline (in children, manubrium or tibia is preffered);
 * Hynk needle is used;
 * after disinfecting the skin and under local anesthesia (mesocain) the bone marrow is punctured and about 0,5–1 ml is aspirated into a syringe;
 * it is stated, that the puncture itself with appropriate anesthesia isn't painful, throughout the aspiration the patient might feel unpleasant pressure (the sound made by a needle when penetrating the bone is unpleasant as well).

Trepanobiopsy

 * A sample of both spongy bone and bone marrow is obtained in the form of a cylinder 15-20 mm high (in addition to marrow, the bone composition is also being determined);
 * Performed out by Jamshidi needle.

Spinal tap

 * Puncture is performed in the subarachnoid space (between arachnoid and pia mater spinalis).
 * Main indications :
 * diagnostically when meningitis is suspected (bacteria and leukocytes are found in cerebrospinal fluid);
 * brain bleed (erythrocytes found in cerebrospinal fluid);
 * therapeutically administrating drugs to CNS (cytostatics in CNS tumors, subarachnoid anesthesia).
 * Performed under L2 vertebra where the spinal cord ends and continues further down as spinal roots - so called cauda equina:
 * between L3 – L4 vertebrae or L4 – L5;
 * the patient is leaning forward (seated or lying on one side), so that the vertebral arches are as far apart as possible;
 * the needle then penetrates the skin and subcutaneous tissue to the spine, between the arches of adjacent vertebrae connected by ligamenta flava finally reaches the spinal canal: at first the epidural space→ through dura mater → subdural space → arachnoid → to subarachnoid space;
 * drip of the cerebrospinal fluid from the inserted needle indicates the penetration into the subarachnoid space.

Related articles

 * Collection of biological material
 * Blood samples for examination