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

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

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.

Links

Related articles

• Collection of biological material
• Blood samples for examination

Sources

• PASTOR, J. Langenbeck's medical web page [online]. [cit. 2009]. <http://www.freewebs.com/langenbeck/>.

External links

• 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