Pericardiocentesis

Indications

  • Cardiac tamponade
    • Beck's Triad (JVD, Hypotension, Distant heart sounds) - unlikely to have all 3
    • Ultrasound
      • Pericardial effusion
      • Diastolic collapse of the right ventricle
      • Diastolic collapse of the right atrium (in atrial diastole)
      • Plethoric IVC
      • Valvular pulsus parodoxus
    • May also see pulsus paradoxus, dyspnea, electrical alternans, low voltage on ECG
  • Diagnose cause of pericardial effusion

Contraindications

Emergent procedure - no absolute contraindications in unstable patient

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: 18ga spinal needle, 20mL (or larger) syringe
    • Can also use abdominal paracentesis kit or central line kit
  • Ultrasound if available; or,
  • Wire with alligator clip connected to base of needle and to any precordial lead of ECG machine
  • If no ultrasound and no alligator clip available, may perform procedure blind

Preparation

  • Bed to 45˚ angle if patient condition allows and you are taking an apical approach (brings heart/pericardium closer to anterior chest wall)
    • Bed flat may work best for subxiphoid approach
  • NG tube if needed to decompress stomach
  • Skin prep with iodine or chlorhexidine, followed by sterile drape
  • Consider sedation or local anesthesia if patient conscious, but do not delay procedure
  • Continuous monitoring (BP, HR, SpO2) during procedure
    • Arterial line ideal, but do not delay procedure.
  • Atropine may be helpful to prevent vasovagal reaction

Technique

Subxiphoid Approach[1]

  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]

  1. If patient condition allows, position in left lateral decubitus to bring effusion towards apex[2]
  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[3]

  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.[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
    • Pericardial fluid will have low pH, low pO2, high pCO2 compared to arterial, venous or mixed venous blood.[5][6]

External Links

ALIEM Pericardiocentesis

See Also

References

  1. 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
  2. ACEP Ultrasound Clinical & Practice Resources - "Appendix: The Core Content of Clinical Ultrasonography Fellowship Training" PDF Accessed 06/17/15
  3. Nagdev, A, et al. A novel in-plane technique for ultrasound-guided pericardiocentesis. American Journal of Emergency Medicine. 2013; 31:1424.e5–1424.e9.
  4. Ainsworth, C.D., & Salehian, O. (2011) "Echo-Guided Pericardiocentesis Let the Bubbles Show the Way". Circulation. 123: e210-e211
  5. 5.0 5.1 Shabetai, R. "The Pericardium". 2003. Springer Science.
  6. Mann W, Millen JE, Glauser FL. Bloody pericardial fluid. The value of blood gas measurements. JAMA. 1978 May 19;239(20):2151-2.