ONCOLOGY PRESENTATION

Presented by:
Namale Joan
Mutense Oscar
Akello Sarah Racheal
Objectives;
By the end of the presentation; students will be able to;
Discuss the following procedures used in oncology outlining indications,
contraindications and complications for each.
1. Thoracentesis
2. Paracentesis
3. Bone marrow aspiration and biopsy
4. Lumbar puncture
5. Fine needle aspiration.
Thoracentesis.
• Thoracentesis or pleural tap, is a procedure in which a needle is inserted into
the pleural space between the lungs and the chest wall to remove excess fluid,
known as a pleural effusion, from the pleural space to help one breathe easier.
Normally the pleural cavity contains only a very small amount of fluid.

• Thoracentesis may be done to determine the cause of your pleural effusion,

which is one of the major causes of pulmonary mortality and morbidity.
Continuation.
• Pleural effusion is the most common disease among all the pleural disease
and affects 1.5 million patients per year in the United States.

• A wide variety of diseases can present with pleural effusions like diseases
primarily involving the lung like pneumonia, asbestos exposure, primarily
systemic diseases like lupus, rheumatoid arthritis, or maybe the pleural
manifestation of diseases which primarily affect other organs like congestive
heart failure, pancreatitis, or diseases local to the pleura like pleural infections
and mesothelioma.
Indications for thoracentesis
• Pleural effusion of unknown origin, concern for empyema, symptomatic
treatment of a large pleural effusion.

• Typically diagnostic thoracentesis is small volume (single 20cc to 30cc

syringe). Unless the cause is obvious, a first-time thoracentesis should have a
diagnostic sample collected for laboratory and pathology analysis.

• Typically, therapeutic thoracentesis is large volume (multiple liters of fluid). A

small sample of a large volume thoracentesis should be sent for analysis when
the etiology of the fluid is unknown or there is a question of a change in the
etiology (e.g., new infection, decompensated chronic condition).
Cont.…
• If the volume of fluid is anticipated to reaccumulate quickly, a drain is often left
in place to collect this fluid. This often is seen in trauma (e.g., hemothorax),
cancer (e.g., malignant effusion), post-operatively (e.g., cardiothoracic post-
operative healing/inflammatory conditions), and end-stage metabolic
conditions with the systemic excessive colloid leak (e.g., cirrhosis or
malabsorption syndromes).

• A fluid collection that is believed to be infected should be drained to eliminate

the source of infection and/or reservoirs of the infection.
• Thoracentesis should be performed diagnostically whenever the excessive fluid is of
unknown cause.

• Thoracentesis also should be performed therapeutically when the volume of fluid is

causing significant clinical symptoms.

Equipment used for thoracentesis

1. thoracentesis kit
2. Chlorhexidine swabs
3. Blood culture bottles
4. Vacutainer bottles
5. Sterile gloves
Procedure for thoracentesis.
1. Using sterile technique, prep and drape the site of insertion.
2. Gel your hands and then put sterile gloves.
3. Cleanse the skin with chlorhexidine.
4. After cleansing the skin, place the fenestrated drape around the procedure
site to create a sterile field and use the large s sterile drape to extend the sterile
field.
Cont.
5. Anesthetize. Draw up 1% lidocaine and first administer just below epidermis
with a 25-gauge needle. Change to the "finder" 18-22 gauge needle. Change to
a 18- 22 gauge needle (1.5 inch) and infiltrate lidocaine on superior aspect of
the lower rib, marching up until you are just above the rib and into the pleural
space.
Cont…..
6. Do not forget to continually draw back on the syringe before injecting the
lidocaine to ensure you are not in a blood vessel as intravenous lidocaine can
be dangerous.

Remember the parietal pleura is a very sensitive structure due to its broad
innervation with a large number of pain fibers.

Make sure to anesthetize this region well, and when you enter the pleural space
inject more lidocaine. For a diagnostic tap, you can use this 18-20 gauge
needle attached to a 20-30 cc syringe.
Cont.
7. If performing a therapeutic tap, use the safety catheter in the kit. Practice
sliding the sheath over the needle.

8. Advance needle over the superior aspect of the low rib, while drawing back
on the syringe.
Cont.….
9. When you obtain fluid, hold the needle steady, while advancing the soft
catheter, then withdraw the needle and place blue clip over needle tip. Never
manipulate the needle with the sheath advanced over it in the patient since this
can lead to shearing of the sheath.

10. Place tubing on to the stopcock and then drain the fluid in your container of
choice.
Cont.
11. Removing pleural fluid too quickly or removing more than 1.5 liters of pleural
fluid increases the chance for reexpansion pulmonary edema.

12. If some fluid comes out and then stops, check your catheter, tubing, etc.
Slowly pull out the catheter or have the patient Valsalva (this can increase
intrathoracic pressure and help the fluid flow).
Cont.…..
• 13. If you aspirate air (see air bubbles in your syringe) or the patient develops
hypotension, desaturation, or respiratory distress, stop immediately and obtain
a CXR or perform immediate needle decompression for tension PTX. If the
patient has recently undergone thoracentesis, however, air bubbles may not
indicate a pneumothorax.

• 14. When removing the needle, have the patient Valsalva to reduce chance of
PTX and bandage the site.

• 15. Complete the procedure, check for complications - mainly pneumothorax

and bleeding.
Contraindications.
• Relative contraindications include any condition in which the potential risk of
the thoracentesis procedure is greater than the probable benefit.

• Common potential risks include coagulopathy, overlying skin/soft-tissue

infection, anatomical variants including congenital defects deforming
identifiable anatomy, acquired anatomical variants such as pleural adhesions,
and collections of fluid that are unlikely to be aspirated via needle drainage
such as a loculated effusion.
Cont.
• Uncooperative patient

• Uncorrected bleeding diathesis (INR >2.5, Plts <25, cr>6), small amount of
fluid (<1 cm to chest wall) chest wall cellulitis at the site of puncture, severely
decreased lung function, high PEEP, or single lung-patient unable to tolerate
possible complication (e.g. pneumothorax or hemothorax)
Complications for thoracentesis
Pneumothorax: Most common symptoms are pleuritic chest pain which may radiate to
the shoulder and shortness of breath, but patients are occasionally asymptomatic.

Pneumothorax should be suspected with symptoms or if air is aspirated in the

thoracentesis syringe.

Diagnose with a CXR. Administer oxygen to patient and use Tylenol and opiates as
appropriate to treat the patient to prevent splinting and atelectasis.

In a tension pneumothorax, the patient may be hypotensive, and the CXR will show
mediastinal shifting. For small pneumothoraces, monitor with serial CXR.

If pneumothorax is large or expanding, or if patient is showing signs of a tension

pneumothorax, call thoracic surgery.
Cont……
• Hemothorax: Occurs as a result of injury to the intercostal arteries.
Hemothorax can be avoided by going above the rib, rather than below, where
the intercostal vessels and nerves are located.

• If a hemothorax is equal to or greater than the amount required to obscure the

costophrenic sulcus or is found in association with a pneumothorax based on
chest radiograph findings, it should be drained by tube thoracostomy.
Cont.
• In cases of hemopneumothorax, 2 chest tubes may be preferred, with the tube
draining the pneumothorax placed in a more superior and anterior position.
Bleeding is usually limited, but ongoing bleeding requires surgical exploration.
Call thoracic surgery.

• Untreated hemothorax can cause fibrothorax or empyema. Metastatic disease

and complications of anticoagulation may cause occult hemorrhage. In these
situations, bleeding into the pleural cavity occurs slowly, resulting in subtle or
absent changes in hemodynamics.

• Check a CBC and LDH on the fluid to help determine whether the RBCs are
old and lysed, or fresh blood.
Cont….
• Vasovagal: Patient may experience a drop in BP and a vagal response to
thoracentesis. Treat supportively with placing the patient in a supine position,
administering oxygen, fluids. Rule out pneumothorax with CXR.
•
• Reexpansion pulmonary edema: Reexpansion pulmonary edema is a rare
complication related to the rapid reexpansion of a chronically collapsed lung,
such as occurs after evacuation of a large amount of air or fluid from the
pleural space.
• The condition usually appears unexpectedly and dramatically. It generally
occurs immediately or within 1 h in 64% of patients, and within 24 h in the
remainder.

• The clinical manifestations are varied; they range from radiographic findings
alone in asymptomatic patients to severe respiratory distress and hypotension
in more serious cases. CXR will show a unilateral alveolar filling pattern.

• The edema may progress for 24-48 h and persist for 4-5 days. There is no
definitive treatment and though treatment is largely supportive: diuretics,
positive pressure ventilation (i.e. BIPAP) and in severe cases intubation are
used
Cont…
• Hepatic and splenic punctures: Largest concern is for intraperitoneal bleed.
With abdominal pain or hypotension, abdominal CT scan is indicated.
Paracentesis.
• A paracentesis is a form of body fluid sampling. A slender needle is used to
withdraw fluid (peritoneal fluid) from the abdomen during a paracentesis
surgery.
• The fluid is collected and submitted to a lab to investigate what is generating
the extra fluid.
• It is most commonly used to diagnose an infection or for cancer patients who
frequently have abdomen fluid or ascites, which can develop due to tumor
pressure and cause discomfort.
Indications for paracentesis
• A paracentesis is performed when a person has a distended abdomen, pain,
or difficulty breathing due to an excess of fluid in the abdomen (ascites)—the
removal of the fluid aids in relieving these symptoms.
• To figure out what’s causing the ascites, the fluid may be sent to a laboratory
for further study to identify
ascites due to various causes
spontaneous bacterial peritonitis in the critical patient
Cont.
abdominal trauma and suspicion of intraperitoneal bleeding - simple puncture
may be followed up by peritoneal washing
the diagnosis of peritonitic acute abdomen – rarely
evacuation of ascites; when high volume ascites causes respiratory
depression through elevation of the diaphragm
Contraindications of paracentesis.
• Acute abdomen requiring immediate surgical intervention
• Coagulation disorders (relative contraindication)
• Intestinal distension
• Previous surgical interventions (relative contraindication) - usually the needle
slides on the intestinal wall (the intestine escapes the needle )
• Post-operation adhesions secure the intestinal loops to the abdominal wall and
expose the intestine to perforation during puncture
• Pregnancy
• Infection at the site chosen for puncture requires choosing another site
Procedure for paracentesis
• Preparing the patient.
• Explain the procedure to the patient; obtain the consent.
• Patient position: - patients with high volume ascites are put in supine position,
in patients with lower volume ascites left lateral decubitus is preferred and
puncture should performed on the left side
• Disinfect the skin by wiping with 3 successive Betadine pads following
standard protocol for preparing the surgical drape.
• Apply the fenestrated drape which leaves the site chosen for the puncture
uncovered
Choosing the puncture site.
• In patients with ascites, the peritoneal liquid surrounds the entire peritoneal
cavity In these patients, perform puncture ; 3-4 cm under the umbilicus or on
the spinoumbilical line, at the intersection of the lateral third and the mid third
of this line, on the left side.

• The left side is preferred, because the sigmoid colon is mobile and escapes
the needle, as opposed to the cecum, which is fixed.
Cont.…..
• In patients with high volume ascites, puncture can be performed in any spot
on the anterior abdominal wall but even in this case, one must avoid areas
with;
Dilated subcutaneous veins (collateral circulation)
Infections (folliculitis, cellulitis)
Hematomas
Post-operatory scars
If there is a small quantity of ascitic fluid or if the fluid is secluded, the best
puncture guiding method is under ultrasound monitoring
Preparing the materials
• The person performing the puncture should put on the sterile gloves, an assistant opens
up the packages of the rest of needed materials and hands them over to the operator.

• Apply a surgical drape on the working table.

• Put all the other sterile materials on this drape:

 A sterile forceps and 3 pads (for preparing the drape)

 A fenestrated drape
 Syringe with anesthetic with a suitable needle
 A 10-20 mL syringe with 18-21 G needle
A container for the collected peritoneal fluid o dressing
• Aspirate the anesthetic in the syringe:
• Have the assistant hold the ampoule.
• Insert the needle into the vial and aspirate the contents.
• Place the filled syringe on the sterile table.
• Thus, the non-sterile ampoule is handled only by the assistant, whereas the
sterile syringe used for aspirating the anesthetic is handled by the operator.
Local anaesthea
• Inject the lidocaine 1% into the skin
• The needle is then inserted further and the parietal peritoneum is injected
• Aspirate from time to time - aspiration of peritoneal fluid confirms the
protrusion of the needle through the peritoneum o avoid aspirating a large
quantity of fluid, which would dilute the remaining anaesthetic
• Retract the needle a couple of millimeters and inject the remaining anaesthetic
Peritoneal puncture
• Insert the needle (18 G) attached to the syringe 10 (20) mL in perpendicular
position in the abdominal wall, at the chosen puncture site
• The needle protrudes successively through the skin, abdominal muscles and
parietal peritoneum.
• In the mean time, maintain negative pressure in the syringe by pulling the
plunger.
• After the needle penetrates the parietal peritoneum, the ascitic fluid (usually
transparent and yellowish) starts filling the syringe
• Progress an extra 2-3 mm and aspirate a sample of fluid in the syringe
CONT.
• Next, retract the needle and apply a dressing at the puncture site.
• Transfer the fluid into the appropriate container.
• Record the procedure in the clinical file of the patient.
• Write down:
 date and time of procedure.
 the anaesthetic used, concentration and quantity.
 puncture site.
 the quantity and quality of the extracted fluid.
 encountered incidents, if any.
Complications for paracentesis
• The procedure can relieve any discomfort produced by ascites while also
being a low-risk operation. It is, nevertheless, typical for the fluid to reappear.
As a result, a patient may need to have the surgery repeated in a few weeks
or have a catheter inserted to allow fluid to drain continually.
• White ( dry ) puncture.
• Fistula with ascitic fluid at the site of puncture - this may be prevented by
employing the Z track technique - if persistent, the fistulous opening is closed
with a cutaneous suture.
• Abdominal wall hematoma
• Perforation of cavity viscera.
• Hypotension.
• Dilutional hyponatremia.
• Exacerbation of hypoproteinemia following evacuation puncture –in cirrhotic
patients with high volume ascites.
BONE MARROW ASPIRATION
• The bone marrow examination is an essential investigation for the diagnosis
and management of many disorders of the blood and bone marrow.

• The aspirate and trephine biopsy specimens are complementary and when
both are obtained, they provide a comprehensive evaluation of the bone
marrow
Choosing a site
• The preferred anatomic site for BM aspiration and trephine biopsy is the
posterior iliac crest.
• The anterior iliac crest can be used if the patient is immobile. The medial
surface of the tibia can also be used in infants.
• A sternal aspirate may be appropriate in certain circumstances, e.g. if the
patient is immobile, has received radiotherapy to the pelvis or other sites have
yielded a ‘dry tap’ or if a trephine biopsy is not required.
CONT.
• Sternal aspiration should only be performed by an experienced operator who
is aware of the risk of cardiac tamponade.
• Sternal aspiration should not be attempted in patients with suspected plasma
cell myeloma or other disorders associated with bone resorption. If there is a
known focal bone lesion (from radiological imaging), diagnostic information
may be obtained if a needle aspirate and bone biopsy is also performed at the
site
Procedure for bone marrow aspiration.
• Special attention to positioning of the patient should be given to immobile
patients, obese patients, pediatric patients or infants, patients with lytic bone
lesions or BM necrosis, or those who have had prior radiotherapy.
• The prior preparations should be ensured.
• The second and third fingers on the hand not being used to insert the needle
should be placed on the iliac crest or spine and the needle inserted between
them.
CONT.
• The needle and stylet are pushed into the bone with a slight rotary motion.
When it is felt that the needle is firmly in place, the stylet is removed and a 10-
or 20-ml plastic syringe is attached.
• The patient is then told that he/she may feel an unpleasant sensation, and the
plunger of the syringe is pulled back vigorously with no more than 0.5 ml of
bone marrow and blood aspirated
Cont.….
• The 10- or 20-ml plastic syringe, attached to the aspiration needle provides
adequate negative pressure.

• 4. Bone marrow smears should be prepared immediately following aspiration

and a report given
Indications for bone marrow biopsy and aspiration
• Bone marrow aspiration and bone marrow biopsy are procedures to collect and examine
bone marrow — the spongy tissue inside some of your larger bones.

• Bone marrow aspiration and bone marrow biopsy can show whether your bone marrow is
healthy and making normal amounts of blood cells. Doctors use these procedures to
diagnose and monitor blood and marrow diseases, including some cancers, as well as
fevers of unknown origin.

• Bone marrow has a fluid portion and a more solid portion. In bone marrow aspiration, a
needle is used to withdraw a sample of the fluid portion. In bone marrow biopsy, a needle
is used to withdraw a sample of the solid portion.

• Bone marrow aspiration can be performed alone, but it's usually combined with bone
marrow biopsy. Together, these procedures may be called a bone marrow exam.
Cont….
1. Investigation of unexplained anemia, abnormal red cell indices, cytopenias
or cytoses.
2. Investigation of abnormal peripheral blood smear morphology, suggestive of
bone marrow pathology.
3. Diagnosis, staging and follow-up of malignant haematological disorders (e.g.
acute and chronic leukaemias, myelodysplastic syndromes, chronic
myeloproliferative disorders, lymphomas, plasma cell myeloma, amyloidosis,
mastocytosis).
4. Investigation of suspected bone marrow metastases.
5. Unexplained focal bony lesions on radiological imaging.
CONT.
6. Unexplained organomegaly or presence of mass lesions inaccessible for
biopsy.
7. Microbiological culture for investigations of pyrexia of unknown origin or
specific infections, e.g. miliary tuberculosis, leishmaniasis, malaria.
8. Evaluation of iron stores.
9. Investigation of lipid/glycogen storage disorders.
10. Exclusion of hematological disease in potential allogeneic stem cell
transplant donors
Complications for bone marrow biopsy and aspiration.
• Excessive bleeding due to thrombocytopenia.

• Skin infection at the site of the exam especially in the immunosuppressed.

• Long-lasting discomfort at the bone marrow exam site.

• Penetration of the sternum during sternal aspirations which can cause damage
to the lungs or heart.
Lumbar puncture
• Lumbar puncture is a procedure in which a thin, hollow needle is inserted into
the lower part of the spine to collect cerebrospinal fluid.
Indications for lumber puncture
• A lumbar puncture may be indicated for both diagnostic and therapeutic
reasons.
• The lumbar puncture may aid in the diagnosis of certain diseases that range
from infectious (encephalitis, meningitis), inflammatory (multiple sclerosis and
Guillain-Barre syndrome), and oncologic to metabolic processes.
• It may also aid in the diagnosis of subarachnoid hemorrhage.
• A lumbar puncture may also be indicated for the intrathecal administration of
certain medications such as analgesics, chemotherapeutic agents, and
antibiotics.
Complications of lumber puncture
The complications of a lumbar puncture include;
• Post-lumbar puncture headache.
• Bleeding, infection, spinal hematoma.
• Cerebral herniation.

NB. Removal of the spinal needle with the stylet in place has been shown to
reduce the incidence of post lumbar puncture headache.
Use of an atraumatic spinal needle (pencil-point spinal needle) and a smaller
gauge is associated with fewer post-lumbar headaches as compared to cutting
needle.
Cont.……
• Spinal hematoma is of particular concern in patients with coagulopathies or
currently receiving certain anticoagulant medications.

• If a spinal subarachnoid hematoma develops, the patient may complain of

acute back pain or new neurologic symptoms.

• The diagnosis can be confirmed with a magnetic resonance imaging (MRI)

scan of the brain.
Contraindications.

• Contraindications to performing a lumbar puncture include;

Skin infection near or at the site of lumbar puncture needle insertion,

Central nervous system (CNS) lesion or spinal mass leading to increased
intracranial pressure,
Platelet count less than 20,000 mm3 (ideally the platelet count should be
greater than 50,000 mm3),
Use of unfiltrated heparin or low-molecular-weight heparin in the past 24 hours,
Coagulopathies (i.e., hemophilia, von Willebrand disease) and vertebral
trauma.
Cont.…..
• A head computed tomogram (CT) should be obtained before performing a
lumbar puncture if there is a concern for increased intracranial pressure.
Fine needle aspiration
• FNA also known as fine needle biopsy is a type of biopsy where a needle is
inserted into a lump or mass to collect a sample of cells.
• The technique of fine-needle aspiration (FNA) biopsy consists of a series of
discrete steps performed in a relatively rapid, smooth, and fluid manner.
• The requisite steps can be divided conceptually into three phases:
preparatory, the actual aspiration, and specimen handling.
• The preparatory phase consists of questioning and examining the patient,
obtaining consent for the procedure, preparing and labeling slides, and
positioning the patient for the aspiration
Cont……
• The actual aspiration involves immobilizing the mass, cleansing the skin,
placing the needle into the mass, and obtaining the specimen.
• The specimen handling phase consists of smear-making and fixation of slides
performed optimally to ensure a top quality specimen for microscopic
examination.
Equipment used for FNA
• Several glass slides,
• A needle and syringe, and
• An alcohol swab for cleansing the skin are required.
• Syringe holder, which allows the aspirator to apply suction with the dominant
hand while firmly fixing the mass with the nondominant hand.
• Culture medium (Thioglycollate broth) is useful in cases suspected of being
infectious in etiology.
• Fixative, usually 95% ethanol, is necessary if some of the smears are to be
stained with Papanicolaou for hematoxy- lin and eosin stains.
 "FNA tray." A hand-held tray can easily be stocked with equipment and materials to perform several FNA
biopsies and is convenient for transporting those materials to clinics or hospital rooms.
Procedure for FNA
• PREPARATORY PHASE
• Before the aspiration, several slides should be labeled with the patient's name
and arranged on a clutter-free work surface; the fixative should be ready for
use, and the syringe holder, syringe, and needle should be assembled and
within reach.

• The next step involves palpating the mass to be aspirated and visualizing the
optimal needle approach to the mass. Once the mass has been located and
firmly fixed with the non dominant hand, the skin is cleansed with an alcohol
swab. Given the small bore needles used in FNA (22 gauge or smaller), local
anesthesia is not generally necessary.
Aspiration phase
• The aspiration should be performed with a small bore needle, generally 23 or
25 gauge, of sufficient length to reach the target lesion; 1½-inch needles are
usually sufficient in the head and neck area.

• The aspirator should be cognizant of the fact that the depth of lesions in soft
tissue tends to be initially underestimated at the time of palpation.

• The needle tip is advanced through the skin and into the center of the mass in
one smooth, rapid motion. Once the needle is in place, suction is applied to
the syringe and the needle tip is moved back and forth within the mass in a
series of short, staccato strokes
Cont…..
• Before removing the needle from the skin, the suction is released, allowing the
plunger to return to its original position.
• If the needle tip exits the skin while suction is being applied, the diagnostic
material may be sucked into the barrel of the syringe where it is less available
for rapid smearing. Ideally, the diagnostic material should be confined to the
bore (and occasionally the hub) of the needle
CONT.
• During the process of aspiration, the aspirator observes the transparent hub of
the needle for the appearance of blood or aspirated material. The appearance
of either signals the end of the aspiration.
• Occasionally blood appears almost immediately, but in other instances, 10 to
20 excursions with the needle can be performed before obtaining material in
the hub. To continue the aspiration process beyond this point results in an
aspirate sample diluted with blood and offers no diagnostic advantage. An
exception is the aspiration of cystic masses.
SPECIMEN HANDLING PHASE
• As mentioned previously, the aspirator should have glass slides labeled with
the patient's name ready to accept the specimen before performing the
aspirates.

• After the needle has been removed from the skin, the material is quickly and
gently expressed onto the slides.

• This is done by removing the needle from the syringe, drawing air into the
syringe, reattaching the needle, and expelling one to two drops of material
onto each slide. Subsequently, direct smears are made by gently spreading
the material with another glass slide.
Cont….
Indications for FNA
• Presence of any lesion or mass in the head and neck
• diagnosing suspected metastatic carcinoma in cervical lymph nodes.
• Enlarged lymph nodes in the neck.
Complications for FNA
• COMPLICATIONS OF FNA IN THE HEAD AND NECK AREA
• needle tract seeding by tumor
• ecchymosis and hematoma
CONT.
• The potential complications of ecchymosis and hematoma formation may be
minimized by having an assistant, or the patient, apply direct firm pressure to
the aspiration site immediately after the needle is withdrawn. If inadvertent
carotid artery puncture occurs, direct pressure should be applied for at least 5
minutes and the patient should be observed following the aspiration. When
performing aspirations in the head and neck, the needle should always be
withdrawn along the same tract that it was inserted to avoid shearing forces,
which could result in a laceration to an artery (rather than a simple puncture
injury, which is more easily controlled).
• Tracheal puncture
• Tracheal puncture may occur during thyroid FNA biopsy. This event is signaled
by "loss of suction" in the syringe. The patient invariably coughs and
occasionally may bring up a small amount of blood. Although this is often a
somewhat startling event for both the patient and the aspirator, it is short-lived
and self-limited.

• vasovagal reactions
• Vigorous palpation of the neck or the action of FNA itself may occasionally
result in a vasovagal reaction. The patient will almost always report the
symptoms to the aspirator. In such cases, the aspiration should be stopped
immediately and the patient should be placed in a "head down" position.
CAROTID BODY TUMORS

• Tumor situated in an anatomic location that raises the possibility of a carotid

body tumor (lesion at the carotid bifurcation) should be approached with
caution and certainly with a very small bore needle such as a 25- or 27-gauge
needle.
• Auscultation over these tumors occasionally reveals a bruit that may serve as
a warning. The danger of aspirating these tumors derives from their rich
vascularity and from their close proximity to the carotid artery.
References.
• Abilitatipracticeluj.ro>eng
• www.ajol.nfo
• Joseph W. Sokolowsji Jr., Guidelines for thoracentesis and needle biopsy of
the pleura.
• E. J. Mayeaux, Jr, MD. Abdominal paracentesis