Pericardiocentesis

Preferred MethodTop

Pericardiocentesis refers to the drainage of pericardial fluid with or without the insertion of a pericardial drain. It is performed percutaneously by a needle, with or without a catheter, and preferably with echocardiographic guidance. The use of ultrasound guidance is associated with a higher success rate, lower complication rate, and lower recurrence rate.

Surgical drainage may be necessary in certain situations, including cardiac tamponade immediately post cardiac surgery or with concomitant issues requiring surgical management (eg, type A dissection, free wall rupture, pseudoaneurysm). There are also other conditions where needle drainage would be difficult or high risk, including hemopericardium with clotted blood, purulent pericardial effusion, or posterior pericardial fluid collection.

Indications Top

1. Therapeutic: Cardiac tamponade (a life-saving procedure).

2. Diagnostic: Pericardial effusion of unclear etiology if the fluid thickness on echocardiography (in diastole) is >20 mm.

Contraindications Top

Cardiac tamponade with aortic dissection (emergency cardiac surgery is necessary). In the case of diagnostic pericardiocentesis, relative contraindications include uncompensated coagulopathy (international normalized ratio [INR] ≥1.5, activated partial thromboplastin time [aPTT] >1.5 × upper limit of normal), anticoagulant treatment, platelet count <50×109/L, and predominantly posterior pericardial effusion.

Potential Complications Top

Perforation of the myocardium or coronary vessels, air embolism, pneumothorax, arrhythmia (usually bradycardia resulting from a vasovagal response), inadvertent puncture of the peritoneum or abdominal organs.

Patient Preparation Top

Obtain informed consent. Place the patient in a supine position. Studies include echocardiography and coagulation tests.

EquipmentTop

1. Equipment for surgical field preparation (see Surgical Field Preparation for Small Procedures) and infiltration anesthesia (see Infiltration Anesthesia).

2. Echocardiography or fluoroscopy equipment (if neither is available, transfer of the patient should be considered when feasible).

3. Long needle with metal stylet (a Tuohy needle, thin-walled 18-gauge needle), central vein catheterization kit (a needle with a guidewire and a single-lumen catheter) or long sheathed angiocatheter and 3-way stopcock.

Site of Pericardiocentesis Top

Most frequently the apical or subcostal (subxiphoid) approach is used. The ideal entry site is the area with the largest fluid pocket on echocardiography that is closest to the skin (this further highlights the importance of ultrasound guidance).

ProcedureTop

1. Prepare the surgical field (see Surgical Field Preparation for Small Procedures) and use infiltration anesthesia of the skin (see Infiltration Anesthesia).

2. Under sterile technique and guidance of echocardiography (bedside) or fluoroscopy (in the cardiac catheterization laboratory) insert the needle (a large-bore angiocatheter or needle used for central venous catheterization) connected to a syringe while aspirating continuously. The needle should be directed towards the largest pocket of pericardial fluid with the needle trajectory based on echocardiographic or fluoroscopic assessment. Needle placement in the pericardial space can be confirmed by instillation of agitated saline and visualizing bubbles in the pericardial space using echocardiography. Once the position is confirmed, fluid can be removed. If ongoing drainage is planned, insert a guidewire through the needle, withdraw the needle, insert a catheter over the guidewire, and remove the guidewire. Extended catheter drainage is associated with reduced rates of recurrence. Secure the catheter with a suture.

3. Drain the fluid in portions <1 L to help avoid acute right ventricular dilation or dysfunction. Maintain the drainage (catheter) until the aspirated fluid volume is <25 to 50 mL over 24 hours.

4. Collect samples for tests as in the case of pleural effusion (eg, cell count, Gram stain, culture, acid-fast bacilli stain, lactate dehydrogenase, protein, cytology).