Pericardiocentesis

Indications

• Cardiac tamponade
• Diagnose cause of pericardial effusion

Contraindications

• No contraindications in patient who is hemodynamically unstable due to tamponade

Relative Contraindications

• Traumatic tamponade (perform ED thoracotomy instead)
• Myocardial rupture
• Aortic dissection
• Bleeding diathesis

Equipment

• Pericardiocentesis kit (contains equipment to perform drain placement via Seldinger technique)
  • If kit unavailable:
    • 18 gauge spinal needle
    • 20mL (or larger) syringe
  • Can also use abdominal paracentesis kit or central line kit
• Ultrasound
• If ultrasound not available:
  • Wire with alligator clip connected to base of needle and cardiac monitor or precordial EKG lead
• If no ultrasound and no alligator clip available, may perform procedure blind as last resort

Preparation

• Obtain consent if able
• Obtain continuous cardiorespiratory monitoring
  • Arterial line is ideal if time permits
• Consider sedation or local anesthesia if time permits and patient is conscious
  • Do not delay procedure in unstable patient
• For apical approach:
  • Bed to 45˚ angle if patient condition allows
    • Brings heart closer to anterior chest wall
• For subxiphoid approach:
  • Bed flat
• NG tube if needed to decompress stomach if time
• Skin prep with iodine or chlorhexidine
• Drape appropriately
• Consider atropine to prevent vasovagal reaction

Technique

Subxiphoid Approach

1. Identify insertion location between xiphoid process and left costal margin
2. Insert needle through skin at identified site at 30-45' angle to the skin, aiming toward left shoulder
3. Remove stylet and attach 3-way stopcock and 20-mL syringe
4. If utilizing ECG, attach alligator clip from base of needle to any precordial ECG lead
5. If utilizing ultrasound, use real-time subxiphoid view to guide needle toward effusion (may also mark location with ultrasound and then perform blind)
6. Slowly advance needle while continually aspirating until fluid return
   1. If utilizing alligator clip, stop advancing needle if ST elevation noted on monitor - withdraw until ST elevations resolve, reposition needle and continue
7. Aspirate fluid (even a small amount can significantly improve patient status)
8. Disconnect syringe/stopcock and use Seldinger technique to place pericardial drain (if needed)
9. Obtain post-procedure CXR to rule-out iatrogenic pneumothorax

Parasternal Approach

1. If patient condition allows, position in left lateral decubitus to bring effusion towards apex
2. Use sterile ultrasonography in parasternal view to identify location of largest area of the effusion (usually around 5th intercostal space)
3. Insert needle through skin at identified site perpendicular to the skin just lateral to the sternum
4. Remove stylet and attach 3-way stopcock and 20-mL syringe
5. Under real-time ultrasound guidance, advance needle while continually aspirating until fluid return
6. Aspirate fluid (even a small amount can significantly improve patient status)
7. Disconnect syringe/stopcock and use Seldinger technique to place pericardial drain
8. Obtain post-procedure CXR to rule-out iatrogenic pneumothorax

Novel In-Plane Technique

1. Skin is prepped
2. Curvilinear probe with sterile cover is placed obliquely over the right chest with indicator to the right shoulder
3. Depth corrected to see only the RV and effusion
4. Needle directed in an in-plane approach at 45°
5. Aspiration is done under direct needle visualization
6. A catheter can be placed under direct visualization using Seldinger technique

Complications

• Cardiac puncture
• Pneumothorax/pneumopericardium
• Dysrhythmias
  • PVC (most common)
  • Vasovagal bradycardia (responsive to atropine)
• False negative (clotted pericardial blood)
• False positive (intracardiac puncture)

Pearls

Ensuring proper placement of the needle/drain in the pericardium is imperative. There are several methods to do this.

• Direct visualization of needle/drain tip on ultrasound.
• Inject small amount of agitated saline under direct ultrasound visualization and evaluate location of bubbles.
• Place small amount of aspirated fluid into a container and evaluate for development of clots.
  • Pericardial fluid will not clot secondary to intrinsic pericardial fibrinolytic activity.
  • However, a rapidly-developing effusion can overwhelm this fibrinolytic activity, causing the fluid to clot.
• Send pericardial fluid for blood gas analysis
  • Pericardial fluid will have low pH, low pO2, high pCO2 compared to arterial, venous or mixed venous blood.

External Links

ALIEM Pericardiocentesis

See Also

• Cardiac tamponade