Pericardiocentesis: Echocardiography-directed pericardial drainage is required for cardiac tamponade due to excess pericardial fluid and to obtain samples of pericardial fluid for the purposes of investigation.
Preparation and equipment required for Pericardiocentesis
Establish peripheral venous access, and check that full facilities for resuscitation are available. Pre-prepared pericardiocentesis sets may be available. You will need:
• A dressing trolley with iodine or chlorhexidine for skin cleansing, dressing pack, sterile drapes, local anaesthetic (lidocaine (INN) 1%), syringes (including a 50 mL), needles (25G and 22G), no. 11 blade, and silk sutures.
• Pericardiocentesis needle (15 cm, 18G) or similar Wallace cannula.
• J-guidewire (≥80 cm, 0.035 diameter), dilators (up to 7F), and a pigtail catheter ≥60 cm long with multiple side holes (a large Seldinger-type CVP line can be used if no pigtail catheters are available).
• Drainage bag and connectors.
• Facilities for echocardiography and occasionally fluoroscopy screening.
Pericardial aspiration technique
• Position the patient at about 30°. This allows the effusion to pool inferiorly within the pericardium.
• Sedate the patient lightly with midazolam (2–5 mg intravenously) and fentanyl (25–100 mcg intravenously), if necessary. Beware a fall in blood pressure in patients with cardiac tamponade who are already compromised by the effusion.
• Sterile technique is essential, including sterile gown, masks, gloves, and drapes. Clean the skin from the mid chest to mid-abdomen, and place the sterile drapes on the patient.
• Infiltrate the skin and subcutaneous tissues with local anaesthetic, starting 1–1.5 cm below the xiphisternum and just to the left of midline, aiming for the left shoulder and staying as close to the inferior border of the rib cartilages as possible.
• The pericardiocentesis needle is introduced into the angle between the xiphisternum and the left costal margin, angled at about 30° to the skin. Advance towards the left shoulder slowly whilst aspirating gently and injecting lidocaine (INN).
• As the parietal pericardium is pierced, the needle may ‘give’ and fluid is aspirated. Remove the syringe, and introduce the guidewire through the needle if a catheter is to be placed.
• Check the position of the guidewire with the echocardiograph (or screening). It should loop within the cardiac silhouette only and not advance into the superior vena cava or pulmonary artery.
• Remove the needle, leaving the wire in place. Enlarge the skin incision slightly, using the blade, and dilate the track.
• Insert the pigtail catheter over the wire into the pericardial space, and remove the wire.
• Take specimens for microscopy; culture, cytology, and haematocrit if bloodstained. Also inoculate a sample into blood culture bottles.
• Aspirate the pericardial space to dryness, watching the patient carefully. Symptoms and haemodynamics (e.g. blood pressure) often improve with the removal of as little as 100 mL of pericardial fluid. If the aspirated fluid is heavily bloodstained, suggesting the catheter is in the right ventricle, withdraw fluid cautiously, as sudden withdrawal of blood may cause cardiovascular collapse. Arrange measurement of an urgent haemoglobin/haematocrit.
• Leave the catheter on free drainage and attached to the drainage bag. Suture the pigtail to the skin securely, and cover with a sterile occlusive dressing.
Pericardial catheter aftercare
• Closely observe the patient for recurrent tamponade (e.g. due to obstruction of drain), and repeat ECHO.
• Discontinue anticoagulants.
• Remove the catheter after 24 hours or when the drainage stops.
• Consider the need for surgery (biopsy or pericardial window) or specific therapy (chemotherapy if malignant effusion, antimicrobials if bacterial, dialysis if renal failure, etc.).
Management tips and pitfalls
• Whenever possible, use echocardiographic guidance.
• If during insertion, the needle touches the heart’s epicardial surface, you may feel a ‘ticking’ sensation transmitted down the needle: withdraw the needle a few millimetres; angulate more superficially, and try again, aspirating as you advance.
• If you do not enter the effusion and the heart is not encountered, withdraw the needle slightly and advance again, aiming slightly deeper, but still towards the left shoulder. If this fails, try again, aiming more medially (e.g. mid-clavicular point). Echocardiographic guidance aids positioning.
• An apical approach (starting laterally at cardiac apex and aiming for right shoulder) may be considered if the echocardiogram confirms sufficient fluid at the cardiac apex.
• If available, intrathoracic ECG can be monitored by a lead attached to the needle, as it is advanced, but is rarely clinically useful. Penetration of the myocardium results in ST elevation, suggesting the needle has been advanced too far.
• Difficulty in inserting the pigtail may be due to insufficient dilatation of the tract and requires use of a larger dilator. Holding the wire taut (by gentle traction), while pushing the catheter, may help; take care not to pull the wire out of the pericardium.
• Differentiating haemorrhagic effusions from intracardiac blood. This can be achieved by:
• Comparing the haemoglobin content of pericardial fluid with that of venous blood.
• Alternatively, place the aspirated fluid in a clean container, and observe whether it clots. Intracardiac blood clots, whereas haemorrhagic effusion does not because the ‘whipping’ action of the heart defibrinates it.
• If it is still unclear whether the catheter is in the pericardial space or the heart, positioning can be confirmed by:
• Injecting contrast (~10–20 mL) and assessing whether it remains intrapericardial, using fluoroscopy or radiology.
• Using echocardiography to detect ‘microbubble contrast’ in the pericardium, following injection of 5–10 mL saline. This is aided by injecting 20 mL saline into a peripheral vein which produces ‘contrast’ in the right atrium and ventricle, distinguishing them from the pericardial space.
• Connecting a pressure transducer to the catheter; a characteristic waveform confirms right ventricular penetration.
Complications of pericardiocentesis
• Penetration of a cardiac chamber (usually right ventricle).
• Laceration of an epicardial vessel.
• Arrhythmia (e.g. atrial arrhythmias as the wire is advanced, ventricular arrhythmias if the RV is penetrated).
• Perforation of abdominal viscus (e.g. liver, stomach, colon).
• Ascending infection.
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