Pericardiocentesis


INDICATIONS
  • Hemopericardium
  • Pericardial effusion with tamponade
  • Pneumopericardium

CONTRAINDICATIONS
  • Relative: Immediately available definitive treatment modalities, ie, pericardial window

List of equipment
Antiseptic (e.g., povidone iodine, ChloraPrep)
Local anesthetic (1% - 2% lidocaine)
25-gauge needle, 5/8 in. long
18-gauge catheter-type needle, 11/2 in. long (for parasternal or apical approaches)
Syringes (10, 20, and 60 mL)
4x4 gauze squares
Plastic tubing
Collection system or basin
US machine
Sterile US probe cover (can be sterile glove)
Sterile drapes
Yankauer suction catheter
Suction tubing
Cardiac monitoring
Optional
18-gauge spinal needle 31/2 in. long (if needed for subxiphoid blind approach)
Alligator clips connected by wire (for ECG approach)
Bedside ECG
Nasogastric tube
Variable angle needle guide attachment for US
Towel clips
#11 scalpel blade
J-tipped guidewire 0.035 mm diameter
6F - 8F pigtail catheter
Three-way stopcock

TECHNIQUE
  • Use ultrasound guidance when available to identify greatest fluid collection.
  • Cardiac monitoring with defibrillator on hand during procedure
  • 7.5 to 12.5 cm 18-Ga needle or Intracath needle should be used.
  • Parasternal approach: Needle is inserted perpendicular to the skin in the left fifth intercostal space. Insertion either just lateral to the sternum or 3 - 4 cm from the sternum should be used to avoid injury to the internal mammilary artery.
  • Subxyphoid approach: Needle is inserted between the xyphoid process and the left costal margin at a 30 - 45 angle to the skin aiming toward the left shoulder (see image below).
  • Parasternal approach has less chance of injury to right atrium but more chance of lung injury compared to subxyphoid approach. During "blind" pericardiocentesis, the subxyphoid approach is recommended.
  • An ECG lead attached to the needle will show a current of injury (typically ST elevation) when the needle touches the ventricular wall. When this occurs, withdraw the needle until the injury pattern is no longer present.
  • Needle will penetrate the pericardium about 6 - 8 cm beneath the skin in adults and <5 cm in children.
  • Obtain CXR to evaluate for pneumothorax.

Optional Steps:

  1. Saline echo-contrast technique. When confirmation of the needle tip is necessary, agitated saline solution can be used. Using a three-way stopcock, attach one end to the catheter. Attach one syringe with 3 mL of NS and one syringe with an equivalent amount of air to the remaining two ports. Quickly mix the saline and air together then inject into the pericardial sac under US visualization. Alternatively, the saline may be agitated by simply shaking a 10-mL syringe filled with 3 to 5 mL of NS and then injecting this into the pericardial space. An echo-contrasted medium should appear in the pericardial space. If the contrast disappears quickly after injection, suspect tip placement in ventricle. Rather than attempting to reinsert needle into the catheter, it is best to start again with a new needle should this complication arise.
  2.  Catheter placement. Using the standard Seldinger technique, a flexible J-tip guidewire is introduced through the catheter. The catheter is then removed. Next, a small "stab" incision is made at the needle entry site. A 6F to 8F dilator is introduced over the guidewire, then removed. A 6F to 8F pigtail catheter is then introduced over the guidewire. The guidewire is then removed. Confirmation of placement can be done by saline echo-contrast as in step 1 above. Catheter is then placed to suction.
  3.  Dressing. Secure catheter to chest wall with suture, dressing, or both.
  4. Catheter drainage and maintenance. Pericardial fluid should be aspirated intermittently approximately every 4 to 6 hours. To prevent catheter blockage, continuous drainage is avoided. Flushing of the catheter with saline after drainage will ensure patency. Strict inputs and outputs should be measured by staff.
  5. Catheter removal. Although not routinely done by ED staff, the catheter may be removed once drainage has decreased to <30 mL in 24 hours. In addition, follow-up 2D echocardiography should confirm resolution of the effusion


 COMPLICATIONS
  • Failure to yield fluid ("dry tap")
  • Myocardial injury possibly leading to hemopericardium
  • Coronary vessel laceration leading to myocardial infarction and/or hemopericardium
  • Dysrhythmia
  • Pneumothorax
  • Pneumoperitoneum

 INTERPRETATION OF RESULTS
  • Removal of even 30 - 50 mL may result in marked clinical improvement.
  • Except in trauma or ventricular wall rupture, pericardial fluid should have a lower hematocrit than venous blood, otherwise suspect that the needle has entered a cardiac chamber (most likely the right ventricle).
  • Injection of a small amount of contrast under fluoroscopy can disclose intracardiac placement.









Subxyphoid approach for Pericerdiocentesis.