Puncture in medicine includes: thoracentesis, bone marrow puncture, lumbar puncture and laparotomy. I. Thoracentesis 1. Overview Thoracentesis is the extraction of fluid from the pleural cavity (between the lung and the chest wall) by using a puncture needle to penetrate through the intercostal space of the chest wall to the pleural cavity. Thoracentesis can be used as a treatment when a large amount of pleural fluid is present in pathological conditions such as tuberculosis. The extracted pleural fluid is examined to identify the nature of the pleural fluid i.e. cancerous pleural fluid, tuberculous pleural fluid etc. Therefore, thoracentesis can be used as a diagnostic method. It is commonly used, simple and effective. Pleural puncture is the abbreviation for pleural cavity puncture. 2, indications (1) traumatic hemopneumothorax (2) diagnostic puncture (3) pleural effusion 3, contraindications (1) the condition of the dying (2) serious bleeding pouring blood, hemoptysis (3) severe tuberculosis and emphysema 4, possible complications (1) post-relaxation hypotension (2) post-relaxation pulmonary edema (3) pneumothorax (4) painful syncope (5) bronchopleural fistula II, bone marrow aspiration 1, overview Bone marrow aspiration (bonemarrowpuncture) is a common diagnostic technique for taking bone marrow fluid, and its examination includes several aspects such as cytology, protozoa and bacteriology. It is suitable for: diagnosis, differential diagnosis and therapeutic follow-up of various hematological diseases. The diagnosis and differential diagnosis of unexplained increase or decrease in the number of red blood cells, white blood cells, platelets and morphological abnormalities. 3. the diagnosis and differential diagnosis of unexplained fever, bone marrow culture, bone marrow smear for parasites, etc. 2. Indications (1) Various causes of anemia and various types of leukemia, thrombocytopenic purpura, multiple myeloma, metastases, myelodysplastic syndrome, myelofibrosis, malignant histiocytosis, etc. (2) Certain parasitic diseases, such as malaria, black fever, etc. can be detected for parasites. (3) Long-term fever, enlargement of liver, spleen and lymph nodes are all feasible for bone marrow aspiration examination to clarify the diagnosis. (4) Bone marrow aspiration can also observe the efficacy of certain diseases. (3) Classification (1) Iliac crest puncture (2) Vertebral spinal tap (3) Sternal puncture 4) Contraindications (1) Bone marrow puncture is contraindicated in patients with hemophilia. (2) No puncture when there is local skin infection or tumor. Many patients feel that bone puncture is a very scary thing, but it is not. The method of bone puncture is very simple. Generally, a small amount of anesthetic is injected locally into the anterior (or posterior) crest of the iliac bone or the sternum, and a small drop of bone marrow tissue is extracted with a bone puncture needle. A skilled physician can perform the entire procedure in just a few minutes. After the bone marrow is extracted, the patient can get up and move around immediately. Some patients think that bone puncture can damage their “vital energy”, but this is also a misconception. The average amount of hematopoietic tissue in a normal person is 2600 grams, and the amount extracted by each bone puncture is only 0.2 to 0.3 grams, plus the fact that bone is a tissue with strong regenerative capacity, which will be generated very quickly after the extraction, so there is no damage to the patient’s health, nor will it cause long-term damage. (1) Diagnosis and differential diagnosis of inflammatory diseases of the central nervous system, including septic meningitis, tuberculous meningitis, viral meningitis, mycobacterial meningitis, type B encephalitis, etc. (2) Diagnosis and differential diagnosis of cerebrovascular accidents include cerebral hemorrhage, cerebral infarction, subarachnoid hemorrhage, etc. (3) Diagnosis and treatment of neoplastic diseases are used to diagnose meningeal leukemia and treat meningeal leukemia by intrathecal injection of chemotherapeutic drugs through lumbar puncture. 2, lumbar puncture mainly has the following purposes (1) to understand the intracranial pressure and whether the cerebrospinal fluid circulation pathway is smooth; (2) to retain cerebrospinal fluid sent for testing: routine, biochemical, bacteriological examination, tumor cell examination, etc.; (3) release of bloody cerebrospinal fluid or high protein cerebrospinal fluid; (4) intrathecal injection (playing drugs). 3, contraindications (1) patients with elevated intracranial pressure. (2) Shock, failure or endangered patients. (3) Local skin (near the puncture site) with inflammation. (4) Patients with bleeding disorders. Lumbar puncture passes through the skin, subcutaneous tissue, supraspinous ligament, interspinous ligament, and ligamentum flavum (into the epidural cavity, where epidural anesthesia is generally referred to), and continues into the needle to penetrate the dura mater and arachnoid, and enters the subarachnoid cavity, where cerebrospinal fluid flows out. Therefore, the feeling of falling in the air twice during puncture, once is the ligamentum flavum and the second is the arachnoid membrane, compared with the stronger feeling of falling in the air in the first time. Peritoneal puncture 1. Definition The puncture technique of piercing the peritoneal cavity with a puncture needle through the abdominal wall is often used to examine the nature of fluid accumulation to help clarify the cause, or to administer intraperitoneal drugs. When there is a large amount of ascites causing dyspnea or abdominal distension and pain, it can also be punctured to release fluid to alleviate the symptoms. The commonly used puncture site in internal medicine is the outer and outer 1/3 intersection of the umbilicus and the anterior superior iliac spine line. 2. Contraindications Laparotomy can be used to identify the cause of ascites (such as portal hypertension, cancer metastasis, tuberculosis, pancreatic ascites), to diagnose visceral perforation in patients with blunt abdominal injuries, and it can also be used for the treatment of ascites in patients with portal hypertension, especially in patients with dyspnea, pain or oliguria due to massive ascites. Absolute contraindications include severe or uncontrolled coagulation abnormalities, intestinal obstruction or abdominal wall infection. Relative contraindications include poor patient cooperation, surgical scarring at the puncture site, or severe portal hypertension with abdominal collateral circulation. 3. Precautions (1) Patients with precursors of hepatic encephalopathy, ovarian cysts, encapsulated worm disease; abdominal puncture to release ascites is contraindicated. (2) Observe the patient closely during the operation. If there is dizziness, palpitation, nausea, shortness of breath, increased pulse rate and pallor, the operation should be stopped immediately and appropriate treatment should be carried out. (3) The fluid release should not be too fast or too much, and the fluid release for cirrhotic patients should not exceed 3000ml at a time, too much fluid release may induce hepatic encephalopathy and electrolyte disturbance. Pay attention to the color change of ascites during the process of fluid release. (4) If the outflow of ascites is not smooth, the puncture needle can be moved slightly or the body position can be changed slightly. (5) After the operation, the patient is asked to lie flat and the puncture hole is located above so that the ascites will not continue to leak out; for those who have more ascites, in order to prevent leakage, attention should be paid to the puncture not to make the eye of the needle from the skin to the peritoneal wall lie in a straight line, by moving the puncture needle slightly around with the assistance of the other hand after the tip of the needle reaches the subcutaneous skin, and then piercing into the abdominal cavity. If the puncture hole continues to have ascites leakage, butterfly tape or fire cotton adhesive can be used. After releasing a large amount of fluid, it is necessary to bundle with a multi-headed lap band to prevent sudden drop in abdominal pressure; visceral vasodilatation causing a drop in blood pressure or shock. (6) Pay attention to aseptic operation to prevent abdominal infection. (7) Abdominal circumference, pulse, blood pressure and abdominal signs should be measured before and after fluid release to inspect changes in condition.