Pericardiocentesis

Indications

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.

Anatomy of the pericardium.

• 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 to decompress stomach if time permits
• Skin prep with iodine or chlorhexidine
• Drape appropriately
• Consider atropine to prevent vasovagal reaction

Technique

Pericardial effusion on ultrasound

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.

Example pericardiocentesis technique.

Subxiphoid Approach

Ultrasound-guided

1. Use ultrasound to identify location of effusion
2. Aiming toward effusion, insert needle through skin using real-time ultrasound guidance and applying negative pressure throughout insertion
3. Remove stylet from needle and attach 3-way stopcock and 20-mL syringe
4. Aspirate fluid
5. Disconnect syringe and stopcock
6. Use Seldinger technique to place pericardial drain if needed for ongoing drainage
7. Obtain post-procedure CXR to rule out iatrogenic pneumothorax

Landmark-guided

1. Identify insertion location between xiphoid process and left costal margin
2. Attach needle to EKG lead using alligator clip and cable (ST elevations will occur on ventricular contact with the needle)
3. Aiming toward left shoulder, insert needle through skin at 30-45' angle, applying negative pressure throughout insertion
4. Remove stylet from needle and attach 3-way stopcock and 20-mL syringe
5. Aspirate fluid
6. Disconnect syringe and stopcock
7. Use Seldinger technique to place pericardial drain if needed for ongoing drainage
8. 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. Under real-time ultrasound guidance, advance needle while continually aspirating until fluid return
5. Remove stylet from needle and attach 3-way stopcock and 20-mL syringe
6. Aspirate fluid
7. Disconnect syringe and stopcock and use Seldinger technique to place pericardial drain if needed
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

• emDocs - Ultrasound Guided Pericardiocentesis
• ALIEM Pericardiocentesis

Videos

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See Also

• Cardiac tamponade
• Pericardial effusion