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

Punctures of body cavities

Puncture of the pleural cavity

Pleural cavity puncture.
  • 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.


Sources


  • 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: <https://portal.jfmed.uniba.sk/clanky.php?aid=169>. ISSN 1337-7396