Puncture

Puncture is a puncture of a body cavity, joint, organ or a pathological structure for diagnostic or therapeutic purposes.

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.

Punctured units

 * Natural cavities (pleural, pericardial, peritoneal, joints, bladder, paranasal sinuses, etc.).
 * Parenchymatous organs (liver, kidneys, spleen, etc.) and bone marrow (aspiration biopsy or trepanobiopsy).
 * Patological 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 ultrasoundu or CT;
 * it is necessary to follow rules of asepsis and use appropriate local anesthetics.
 * Puncture needles:
 * vary in diameter and length;
 * some have 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 punctions include:
 * bleeding,
 * peritonitis,
 * fistula formation,
 * tumor metastasis to the puncture canal,
 * pneumotorax,
 * pankreatitis in pancreatic punctures.

Puncture of the pleural cavity
náhled|Punkce pleurální dutiny.
 * Based on the indication (gas, liquid) twp approaches are used:
 * 1) according to Monaldi – puncture of pneumotorax – in the 2nd or 3rd intercostal space in medioclavicular line, in half-sitting position;
 * 2) according to Bullau – puncure of fluidotoraxu – in 6th intercostal space in 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 left Larrey's 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 collarbone;
 * ECG elektrode can be attatched to the needle.
 * If the intracardial drug administration is necessary (resuscitation), we puncture the left ventricle obliquely in 5th intercostal space in medioclavicular line.

Pucture of peritoneal cavity

 * Indicated primarrily in ascites as a relieving procedure and for the examination of the fluid obtained by the puncture;
 * administered to the outer side from the center of umbilical-spinous line at Monroo point;
 * puncture of Douglas space in women performed through posterior vaginal vault, in absces in Douglas space transrectal approach is possible;
 * 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 in 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 feels unpleasant pressure (the sound made by a needle when penetrating the bone is also unpleasant).

Trepanobiopsy

 * Získává se vzorek spongiózy se dření ve formě válečku vysokého 15–20 mm (kromě dřeně se zjišťuje také složení kosti);
 * provádí se Jamshidiho jehlou.

Lumbální punkce

 * Punkce se provádí v subarachnoidálním prostoru (mezi arachnoideou a pia mater spinalis).
 * Hlavní indikace:
 * diagnosticky při podezření na meningitidu (v likvoru se naleznou bakterie a leukocyty);
 * krvácení do mozku (v likvoru se naleznou erythrocyty);
 * terapeuticky při aplikaci některých léků do CNS (cytostatika u tumorů CNS, subarachnoidální anestézie).
 * Provádí se pod úrovní obratle L2 kde končí mícha a dále kaudálně pokračuje jako míšní kořeny – tzv. cauda equina:
 * mezi obratli L3 – L4 nebo L4 – L5;
 * pacient je v předklonu (vsedě nebo vleže na boku), aby se od sebe obratlové oblouky co nejvíce oddálily;
 * jehla pak proniká kůží a podkožím k páteři, mezi oblouky sousedních obratlů, jež spojují ligamenta flava se dostává do páteřního kanálu: nejprve do epidurálního prostoru→ přes dura mater → subdurální prostor → arachnoideu → do subarachnoidálního prostoru;
 * pro průnik do subarachnoidálního prostoru svědčí odkapávání likvoru ze zavedené jehly.

Související články

 * Odběry biologického materiálu
 * Odběry krve na vyšetření

Externí odkazy

 * Osacká Petronela: Punkcie. Multimediálna podpora výučby klinických a zdravotníckych disciplín :: Portál Jesseniovej lekárskej fakulty Univerzity Komenského [online] 2.12.2011, posledná aktualizácia 15.12.2011 [cit. 2011-12-23] Dostupný z WWW: . ISSN 1337-7396