Pericardiocentesis: Difference between revisions
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==Indications== | ==Indications== | ||
[[File:Body Cavities Frontal view labeled 2.jpg|thumb|The pericardial cavity in this image is labeled d and is part of the inferior mediastium. Here we can see its relation to the superior mediastinum a, the pleural cavities c, and the diaphragm e.]] | |||
[[File:2004 Heart Wall.jpg|thumb|Anatomy of the pericardium.]] | |||
*[[Cardiac tamponade]] | |||
*Diagnose cause of [[pericardial effusion]] | |||
==Contraindications== | ==Contraindications== | ||
*No contraindications in patient who is hemodynamically unstable due to tamponade | |||
===Relative Contraindications<ref name="NEJM">Fitch MT, Nicks BA, Pariyadath M, McGinnis HD, Manthey DE. Emergency Pericardiocentesis. N Engl J Med. 2012 Mar 22;366(12):e17</ref>=== | |||
*Traumatic tamponade (perform ED [[thoracotomy]] instead) | |||
*[[Myocardial rupture]] | |||
*[[Aortic dissection]] | |||
*[[coagulopathy|Bleeding diathesis]] | |||
==Equipment== | ==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 to decompress stomach if time permits | |||
*Skin prep with iodine or chlorhexidine | |||
*Drape appropriately | |||
*Consider atropine to prevent vasovagal reaction | |||
==Technique== | ==Technique== | ||
[[File:PericardialeffusionUS.png|thumb|[[Pericardial effusion]] on ultrasound]] | |||
[[File:PMC4613420 IJCIIS-5-206-g001.png|thumb|Ultrasound-guided pericardiocentesis in a patient with malignant pericardial effusion and tamponade. (a) Apical view of the heart showing large circumferential pericardial effusion (arrow); (b) Intrapericardial injection of agitated saline (whitish-gray cloud of microbubbles of air) verifies correct positioning of the pericardiocentesis needle (arrow); and (c) following pericardiocentesis, the right ventricle has expanded and no residual pericardial effusion is seen within the pericardial sac (arrow). LV = left ventricle; RV = right ventricle.]] | |||
[[File:PMC3518705 kcj-42-725-g007.png|thumb|Example pericardiocentesis technique.]] | |||
===Subxiphoid Approach<ref name="NEJM" />=== | |||
== | ====Ultrasound-guided==== | ||
#Use ultrasound to identify location of effusion | |||
#Aiming toward effusion, insert needle through skin using real-time ultrasound guidance and applying negative pressure throughout insertion | |||
#Remove stylet from needle and attach 3-way stopcock and 20-mL syringe | |||
#Aspirate fluid | |||
#Disconnect syringe and stopcock | |||
#Use Seldinger technique to place pericardial drain if needed for ongoing drainage | |||
#Obtain post-procedure CXR to rule out iatrogenic pneumothorax | |||
== | ====Landmark-guided==== | ||
# | #Identify insertion location between xiphoid process and left costal margin | ||
# | #Attach needle to EKG lead using alligator clip and cable (ST elevations will occur on ventricular contact with the needle) | ||
# | #Aiming toward left shoulder, insert needle through skin at 30-45' angle, applying negative pressure throughout insertion | ||
# | #Remove stylet from needle and attach 3-way stopcock and 20-mL syringe | ||
#Aspirate fluid | |||
#Disconnect syringe and stopcock | |||
#Use Seldinger technique to place pericardial drain if needed for ongoing drainage | |||
#Obtain post-procedure CXR to rule out iatrogenic pneumothorax | |||
===Parasternal Approach<ref name="NEJM" />=== | |||
#If patient condition allows, position in left lateral decubitus to bring effusion towards apex<ref>ACEP Ultrasound Clinical & Practice Resources - "Appendix: The Core Content of Clinical Ultrasonography Fellowship Training" [https://www.acep.org/workarea/downloadasset.aspx?id=95794 PDF] Accessed 06/17/15</ref> | |||
#Use sterile ultrasonography in parasternal view to identify location of largest area of the effusion (usually around 5th intercostal space) | |||
#Insert needle through skin at identified site perpendicular to the skin just lateral to the sternum | |||
#Under real-time ultrasound guidance, advance needle while continually aspirating until fluid return | |||
#Remove stylet from needle and attach 3-way stopcock and 20-mL syringe | |||
#Aspirate fluid | |||
#Disconnect syringe and stopcock and use Seldinger technique to place pericardial drain if needed | |||
#Obtain post-procedure CXR to rule out iatrogenic pneumothorax | |||
===Novel In-Plane Technique<ref>Nagdev, A, et al. A novel in-plane technique for ultrasound-guided pericardiocentesis. American Journal of Emergency Medicine. 2013; 31:1424.e5–1424.e9.</ref>=== | |||
#Skin is prepped | |||
#Curvilinear probe with sterile cover is placed obliquely over the right chest with indicator to the right shoulder | |||
#Depth corrected to see only the RV and effusion | |||
#Needle directed in an in-plane approach at 45° | |||
#Aspiration is done under direct needle visualization | |||
#A catheter can be placed under direct visualization using Seldinger technique | |||
==Complications== | ==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.<ref>Ainsworth, C.D., & Salehian, O. (2011) "Echo-Guided Pericardiocentesis | |||
Let the Bubbles Show the Way". Circulation. 123: e210-e211</ref> | |||
*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.<ref name="Pericardium">Shabetai, R. "The Pericardium". 2003. Springer Science.</ref> | |||
**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.<ref name="Pericardium" /><ref>Mann W, Millen JE, Glauser FL. Bloody pericardial fluid. The value of blood gas measurements. JAMA. 1978 May 19;239(20):2151-2.</ref> | |||
==External Links== | |||
*[http://www.emdocs.net/core-em-ultrasound-guided-pericardiocentesis/ emDocs - Ultrasound Guided Pericardiocentesis] | |||
*[http://www.aliem.com/ultrasound-guided-pericardiocentesis/ ALIEM Pericardiocentesis] | |||
===Videos=== | |||
{{#widget:YouTube|id=XqZKK3J4cwo}} | |||
==See Also== | |||
*[[Cardiac tamponade]] | |||
*[[Pericardial effusion]] | |||
==References== | |||
<references/> | |||
[[Category: | [[Category:Cardiology]] | ||
[[Category:Procedures]] | [[Category:Procedures]] | ||
[[Category:Critical Care]] |
Latest revision as of 18:02, 12 April 2022
Indications
- Cardiac tamponade
- Diagnose cause of pericardial effusion
Contraindications
- No contraindications in patient who is hemodynamically unstable due to tamponade
Relative Contraindications[1]
- 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
- If kit unavailable:
- 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
- Bed to 45˚ angle if patient condition allows
- For subxiphoid approach:
- Bed flat
- NG tube to decompress stomach if time permits
- Skin prep with iodine or chlorhexidine
- Drape appropriately
- Consider atropine to prevent vasovagal reaction
Technique
Subxiphoid Approach[1]
Ultrasound-guided
- Use ultrasound to identify location of effusion
- Aiming toward effusion, insert needle through skin using real-time ultrasound guidance and applying negative pressure throughout insertion
- Remove stylet from needle and attach 3-way stopcock and 20-mL syringe
- Aspirate fluid
- Disconnect syringe and stopcock
- Use Seldinger technique to place pericardial drain if needed for ongoing drainage
- Obtain post-procedure CXR to rule out iatrogenic pneumothorax
Landmark-guided
- Identify insertion location between xiphoid process and left costal margin
- Attach needle to EKG lead using alligator clip and cable (ST elevations will occur on ventricular contact with the needle)
- Aiming toward left shoulder, insert needle through skin at 30-45' angle, applying negative pressure throughout insertion
- Remove stylet from needle and attach 3-way stopcock and 20-mL syringe
- Aspirate fluid
- Disconnect syringe and stopcock
- Use Seldinger technique to place pericardial drain if needed for ongoing drainage
- 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)
- Insert needle through skin at identified site perpendicular to the skin just lateral to the sternum
- Under real-time ultrasound guidance, advance needle while continually aspirating until fluid return
- Remove stylet from needle and attach 3-way stopcock and 20-mL syringe
- Aspirate fluid
- Disconnect syringe and stopcock and use Seldinger technique to place pericardial drain if needed
- Obtain post-procedure CXR to rule out iatrogenic pneumothorax
Novel In-Plane Technique[3]
- Skin is prepped
- Curvilinear probe with sterile cover is placed obliquely over the right chest with indicator to the right shoulder
- Depth corrected to see only the RV and effusion
- Needle directed in an in-plane approach at 45°
- Aspiration is done under direct needle visualization
- 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.[4]
- 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.[5]
- However, a rapidly-developing effusion can overwhelm this fibrinolytic activity, causing the fluid to clot.
- Send pericardial fluid for blood gas analysis
External Links
Videos
{{#widget:YouTube|id=XqZKK3J4cwo}}
See Also
References
- ↑ 1.0 1.1 1.2 Fitch MT, Nicks BA, Pariyadath M, McGinnis HD, Manthey DE. Emergency Pericardiocentesis. N Engl J Med. 2012 Mar 22;366(12):e17
- ↑ ACEP Ultrasound Clinical & Practice Resources - "Appendix: The Core Content of Clinical Ultrasonography Fellowship Training" PDF Accessed 06/17/15
- ↑ Nagdev, A, et al. A novel in-plane technique for ultrasound-guided pericardiocentesis. American Journal of Emergency Medicine. 2013; 31:1424.e5–1424.e9.
- ↑ Ainsworth, C.D., & Salehian, O. (2011) "Echo-Guided Pericardiocentesis Let the Bubbles Show the Way". Circulation. 123: e210-e211
- ↑ 5.0 5.1 Shabetai, R. "The Pericardium". 2003. Springer Science.
- ↑ Mann W, Millen JE, Glauser FL. Bloody pericardial fluid. The value of blood gas measurements. JAMA. 1978 May 19;239(20):2151-2.