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INTRODUCTION

Internists perform a wide range of medical procedures, although practices vary widely among institutions and by specialty. Internists, nurses, or other ancillary health care professionals perform venipuncture for blood testing, arterial puncture for blood gases, endotracheal intubation, and flexible sigmoidoscopy, and insert IV lines, nasogastric (NG) tubes, and urinary catheters. These procedures are not covered here, but require skill and practice to minimize pt discomfort and potential complications. Here, we review more invasive diagnostic and therapeutic procedures performed by internists—thoracentesis, lumbar puncture, and paracentesis. Many additional procedures are performed by specialists and require additional training and credentialing, including the following:

  • Allergy—skin testing, rhinoscopy

  • Cardiology—stress testing, echocardiograms, coronary catheterization, angioplasty, stent insertion, pacemakers, electrophysiology testing and ablation, implantable defibrillators, cardioversion

  • Endocrinology—thyroid biopsy, dynamic hormone testing, bone densitometry

  • Gastroenterology—upper and lower endoscopy, esophageal manometry, endoscopic retrograde cholangiopancreatography, stent insertion, endoscopic ultrasound, liver biopsy

  • Hematology/Oncology—bone marrow biopsy, stem cell transplant, lymph node biopsy, plasmapheresis

  • Pulmonary—intubation and ventilator management, bronchoscopy

  • Renal—kidney biopsy, dialysis

  • Rheumatology—joint aspiration

Increasingly, ultrasound, CT, and MRI are being used to guide invasive procedures, and flexible fiberoptic instruments are extending the reach into the body. For most invasive medical procedures, including those reviewed below, informed consent should be obtained in writing before beginning the procedure.

THORACENTESIS

Drainage of the pleural space can be performed at the bedside. Indications for this procedure include diagnostic evaluation of pleural fluid, removal of pleural fluid for symptomatic relief, and instillation of sclerosing agents in pts with recurrent, usually malignant pleural effusions.

PREPARATORY WORK

Familiarity with the components of a thoracentesis tray is a prerequisite to performing a thoracentesis successfully. Recent PA and lateral chest radiographs with bilateral decubitus views should be obtained to document the free-flowing nature of the pleural effusion. Loculated pleural effusions should be localized by ultrasound or CT prior to drainage.

TECHNIQUE

A posterior approach is the preferred means of accessing pleural fluid. Comfortable positioning is a key to success for both pt and physician. The pt should sit on the edge of the bed, leaning forward with the arms abducted onto a pillow on a bedside stand. Pts undergoing thoracentesis frequently have severe dyspnea, and it is important to assess if they can maintain this positioning for at least 10 min. The entry site for the thoracentesis is based on the physical exam and radiographic findings. Percussion of dullness is utilized to ascertain the extent of the pleural effusion with the site of entry being the first or second highest interspace in this area. The entry site for the thoracentesis is at the superior aspect of the rib, thus avoiding the intercostal nerve, artery, and vein, which run along the inferior aspect of the rib (Fig. 4-1).

FIGURE 4-1

In thoracentesis, the needle is passed over the top of the rib to ...

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