Pericardiocentesis

Pericardiocentesis is a procedure that can be performed to withdraw pericardial fluid as a therapeutic intervention or a diagnostic modality.

Indications

• diagnostic
  • pericardial effusion of an unknown etiology
• therapeutic
  • relief of pericardial tamponade

Contraindications

• absolute
  • none (given profound hemodynamic instability or cardiac arrest)
• relative ³
  • coagulopathy
  • cardiac device/pacemaker
  • prosthetic valve
  • traumatic hemopericardium
  • aortic dissection
  • myocardial rupture

Procedure

In the presence of incipient or actual cardiac arrest, the procedure may be performed using landmark and/or electrocardiographic guidance with an 18 gauge spinal needle mounted on a 10 milliliter syringe ³. The needle is typically held at 30 degrees to the skin and inserted 1 cm caudad to the left xiphisternal angle, maintaining negative pressure while advancing the needle toward the left shoulder. The preferred method, however, involves the use of image guidance, such as fluoroscopy or ultrasonography.

Preprocedural evaluation

Ultrasound can quickly locate the largest and most accessible pocket of pericardial fluid, which may influence subsequent choice of puncture location. Several approaches have been described in the literature, including:

• subxiphoid
• parasternal ⁴
• apical

Positioning/room set up

If possible the head of the bed should be elevated to between 30 and 45 degrees to facilitate proximity of the heart and the chest wall. The anterior hemithorax and upper abdomen should be liberally scrubbed with chlorhexidine. Personal protective equipment should be donned, and the patient should be draped, leaving only the area around the xiphoid process (or alternative desired puncture location) exposed. If the patient is conscious, the skin and desired needle course should be anesthetized.

Technique

The ultrasound transducer with sterile sheath should then be used to revisualize the targeted fluid collection, and an 18-gauge spinal needle is mounted on a sterile, saline-filled syringe. Leaving the ultrasound probe on the chest wall, the needle is inserted in close proximity to the footprint of the probe, and advanced into the field of view. Negative pressure should be maintained while advancing the syringe. The needle may then be visualized as it enters the pericardial space. Upon visualized entry, agitated saline may be used to further confirm placement; punctate, echogenic particles will be seen to enter and remain in the pericardial space, with rapid egress suggesting a possible intracardiac placement of the needle. Subsequent aspiration of pericardial fluid should result in an immediate improvement in hemodynamics in a patient with pericardial tamponade.

A temporary pericardial drain, usually a pigtail angiocatheter, then may be placed using the Seldinger technique and sutured in place, which allows continued drainage and mitigates reaccumulation of pericardial fluid.

Postprocedural care

A post-procedural chest radiograph should be obtained to evaluate for the presence of complications such as intraabdominal viscus perforation, pneumothorax, and hemothorax ³.

Complications

• arterial injury
  • coronary arteries
  • intercostal arteries
  • internal mammary artery
• systemic air embolism
• pneumopericardium
• hemothorax
• pneumothorax
• transient left ventricular dysfunction ²