From WikiLectures

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

Puncture division[edit | edit source]

  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[edit | edit source]

  • 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[edit | edit source]

  • 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[edit | edit source]

Punctures of body cavities[edit | edit source]

Puncture of the pleural cavity[edit | edit source]

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[edit | edit source]

  • 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[edit | edit source]

  • 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[edit | edit source]

  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[edit | edit source]

  • 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[edit | edit source]

  • 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[edit | edit source]

  • 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 matersubdural spacearachnoid → to subarachnoid space;
    • drip of the cerebrospinal fluid from the inserted needle indicates the penetration into the subarachnoid space.

Links[edit | edit source]

Related articles[edit | edit source]

Sources[edit | edit source]

External links[edit | edit source]

  • 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