Pericardiocentesis is performed to remove fluid from the pericardium
for diagnostic purposes or as a therapy for pericardial tamponade.
- ▪ 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
- ▪ Indications for pericardiocentesis:
- —Pericardial tamponade
- —Pericardial effusion
- —Pericardial fluid drainage where purulent effusion
- —Diagnosis of etiology for effusion
- ▪ Contraindications:
- —Small or loculated effusion, where surgery is the
- —Prior to procedure, obtain patient consent, prep
and drape, and perform universal protocol as described in Section
- —Identify drainage site based on echocardiography
- ▪ 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
- —The needle is inserted under the xiphoid at a 20
angle to the skin and directed toward the left shoulder (Figure
- —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- —The needle is then withdrawn and a pigtail catheter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
Graphic showing anatomic approach to pericardiocentesis.
Pigtail drainage catheter.
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 ...