Chapter 41. Pericardiocentesis

Introduction

Pericardiocentesis is performed to remove fluid from the pericardium for diagnostic purposes or as a therapy for pericardial tamponade.

Definitions and Terms

• ▪  Pericardial tamponade: Clinical scenario in which fluid accumulates in the pericardial sac to the point that pericardial pressure impedes venous return to the heart—this may occur acutely as with an injury to the heart or chronically, wherein a large amount of fluid accumulates over time.
• ▪  Pericardial effusion: Accumulation of fluid in the pericardial sac.

Techniques

• ▪  Indications for pericardiocentesis:
  • —Pericardial tamponade
  • —Pericardial effusion
  • —Pericardial fluid drainage where purulent effusion suspected
  • —Diagnosis of etiology for effusion
• ▪  Contraindications:
  • —Coagulopathy.
  • —Small or loculated effusion, where surgery is the preferred alternative.
  • —Prior to procedure, obtain patient consent, prep and drape, and perform universal protocol as described in Section I.
  • —Identify drainage site based on echocardiography or fluoroscopy.
• ▪  Preparation:
  • —Skin: The Center for Disease Control and Prevention (CDC) recommends preparation of the cannulation site with a 2% aqueous chlorhexidine-gluconate solution, which has been associated with lower blood stream infection rates than povidone-iodine or alcohol-based preparations. The skin and tissue around over the site should be infiltrated with 1% lidocaine solution, except in patients with a known allergy to lidocaine, in whom alternative local anesthetics can be used.
  • —Hygiene: The operator should observe proper hand hygiene and use maximal barrier precautions including gown, mask and gloves, and a large sterile drape or multiple drapes covering a large area.
• ▪  Methods:
  • —Position patient with head of bed elevated to pool effusion in the dependent portion of the pericardial sac.
  • —A sterile electrocardiograph (ECG) lead should be attached to the pericardiocentesis needle (which may be a spinal needle).
  • —The needle is inserted under the xiphoid at a 20 angle to the skin and directed toward the left shoulder (Figure 41-1).
  • —The ECG is monitored continuously for injury current as the needle is advanced.
  • —The needle is advanced until there is fluid return or an injury current (ST elevation) on the ECG.
  • —If fluid is aspirated, a flexible guidewire is inserted through the needle into the effusion.
  • —The needle is then withdrawn and a pigtail catheter (Figure 41-2) inserted over the wire and secured in place if the catheter is to be left in place.
  • —Fluid is then drained from the pericardium and sent for diagnostic studies as indicated.
• ▪  Complications:
  • —Pericardial tamponade
  • —Coronary artery or vein laceration
  • —Cardiac ectopy
  • —Pneumothorax

Clinical Pearls and Pitfalls

• ▪  So-called “blind” pericardiocentesis can be performed in the event of an emergency, but echocardiographically guided procedures are preferable (Figure 41-3).
• ▪  Echo ...