Pericardiocentesis


Article Author:
Daniel Willner


Article Editor:
Shamai Grossman


Editors In Chief:
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Mayank Singhal


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Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
2/11/2019 8:43:52 PM

Introduction

Pericardiocentesis is a procedure performed to remove pericardial fluid from the pericardial sac. It is often performed in the setting of pericardial tamponade to correct hypotension due to decreased stroke volume from extrinsic compression of the chambers of the heart.

Pericardiocentesis is performed using one of several approaches and may be performed blind or using real-time imaging adjuncts such as transthoracic echocardiography (TTE) or fluoroscopy to reduce the risk of procedural complications. The procedure may be performed at the bedside or in the cardiac catheterization lab. The decision on where to perform the procedure and what adjuncts to use is based on the stability of the patient, comfort of the operator, and availability of imaging adjuncts.[1][2][3]

Indications

There are numerous indications for pericardiocentesis. Either blunt or penetrating traumatic injuries may cause accumulation of blood in the pericardial space (hemopericardium) and cardiac tamponade. Penetrating trauma to "the box" (the region of the anterior chest delineated superiorly by the clavicles, inferiorly by the costal margin, and laterally by the nipple line) from projectiles or sharp-tipped objects has the potential to injure any of the structures in the area and cause pericardial tamponade. Pericardiocentesis is indicated in blunt or penetrating trauma patients who present with hemodynamic instability, cardiac arrest - most commonly used or Pulseless Electrical Activity (PEA) or asystole, or evidence of a pericardial effusion on the Focused Assessment with Sonography for Trauma (FAST) exam and hypotension without another clear etiology. This procedure is performed emergently at the bedside as a temporizing measure to stabilize the patient and facilitate transfer to the operating room (OR) where definitive treatment, such as the creation of a pericardial window or thoracotomy and surgical pericardiotomy, can be performed. If the pericardiocentesis is unsuccessful, a bedside thoracotomy can be performed to allow for pericardiotomy and drainage of pericardial tamponade.[4][5]

Contraindications

There are no absolute contraindications to pericardiocentesis. Even withdrawal of a small amount of fluid in a very unstable patient can lead to immediate improvement in hemodynamics. Relative contraindications include uncorrected coagulopathy, low platelet count and lack of knowledge about the anatomy of the chest.

Equipment

The procedure should be done in the operating room or the ICU where the patient can be continuously monitored. Besides having an ECHO machine one needs sterile drapes, local anesthetic, syringes, needles, scalpel and a pericardiocentesis kit. An alligator clip connector is needed to connect the V1 lead to the ECG machine. The patient is placed supine with the head of the bed slightly elevated. The patient must have IV access, receive oxygen and be hooked on to a cardiac monitor. If time permits, a nasogastric tube to decompress the stomach is recommended to lower the risk of gastric perforation.

Personnel

Pericardiocentesis should only be performed by healthcare workers familiar with the anatomy of the heart. This is not a learning procedure for a first timer as it has the potential to cause serious injury to the heart. The procedure should follow strict aseptic rules using personnel from the operating room or cardiac catheterization laboratory.

Preparation

Pericardiocentesis is performed for medical patients either as a therapeutic or diagnostic procedure. Pericardiocentesis is indicated when either an acute or a chronic pericardial effusion causes cardiac tamponade. Pericardiocentesis in acute or chronic pericardial effusions without evidence of cardiac tamponade and other non-emergent situations is indicated for diagnosis of the underlying etiology of the effusion by obtaining pericardial fluid for laboratory analysis, for palliation of symptoms including dyspnea or edema, or to prevent progression of the effusion to pericardial tamponade an emergent situation.  In the acute setting, only a small amount of pericardiac fluid (100-150 mL) is necessary to cause cardiac tamponade while in chronic pericardial effusions as much as 1-2 L of pericardial fluid may accumulate as long as the parietal pericardium has adequate time to adjust to the increasing volume. Pericardiocentesis can be performed at the bedside in the same manner as for traumatic pericardial tamponade, or the patient may be resuscitated with IV fluids and taken the cardiac catheterization lab for pericardiocentesis performed using TTE or fluoroscopic guidance and with monitoring of right-sided heart pressures. In situations where reaccumulation of pericardial fluid is expected a pericardial drain may be to facilitate serial drainage.

Technique

Anatomic approaches to pericardiocentesis include needle insertion via the subxiphoid approach or anterior chest. Both may be performed using either ultrasound or fluoroscopy for guidance. The area is prepped and draped in a sterile fashion, and a large bore (20 gauge or larger) needle of sufficient length is then inserted through the skin and into the pericardial sac. If the pericardiocentesis is being performed blind (without real-time guidance via TTE or fluoroscopy) and fluid is not encountered on the first pass then the needle is withdrawn to the skin and adjusted as deemed appropriate by the operator moving sequentially across the anticipated position of the heart and pericardial sac until fluid is encountered.

Complications

Complications of pericardiocentesis include injury to the myocardium with the potential for hemorrhage into the pericardium and pericardial tamponade, pneumothorax, injury to the great vessels, injury to the liver or abdominal viscera, arrhythmia, and infection.[6][7]

Clinical Significance

Pericardiocentesis is a life-saving procedure. Failure to perform the procedure when indicated will result in pericardial tamponade and death.

Over the years several methods have been used to differentiate the fluid from the pericardium and the cardiac cavity. None is perfect, and one must use clinical judgment. If the aspirated fluid forms a lot, then the fluid is from a cardiac chamber, whereas pericardial fluid does not clot. The pericardial fluid should have a lower hematocrit or hemoglobin level compared to the blood. If an intracardiac injection of fluorescein is performed, then one may see the fluorescein in the conjunctiva.

If the heart chamber has been entered with the needle, one should pull out the needle and observe the patient. In most cases, there will be no leakage of blood into the pericardial cavity. However, if the pericardium starts to accumulate blood, a cardiac surgeon should be notified right away. Closing a hole in the myocardium while the heart is beating requires skill and the most important thing is not to occlude any nearby coronary artery.

Enhancing Healthcare Team Outcomes

Pericardiocentesis is a major procedure with the potential of causing life-threatening injuries. The procedure is always performed by a cardiologist, cardiac surgeon or radiologist but the role of the pharmacist and nurse is indispensable. The pharmacist may be required to assist in pain control. Prior to the procedure, the patient must have an informed consent and be told about the risks and benefits of the procedure. Patient positioning and monitoring during and after the procedure are also major requirements. While the procedure is done under local anesthesia, the nurse often provides assurance and comfort to the patient, while at the same time, monitoring the vital signs. After the procedure, the patient is maintained at bed rest for 12-24 hours but the vitals needs to be monitored until stable. If a drain is left inside the pericardium, the nurse should record the drainage every shift. [8][9](Level III)

Outcomes

Pericardiocentesis, when done in the hands of experienced physicians, has good outcomes but complication rates still occur in about 5-40% of cases. Most complications present early and need immediate attention. The use of ultrasound or fluoroscopy is highly recommended to lower the risk of complications. [7][10](Level III)


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Pericardiocentesis - Questions

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For aspiration of pericardial fluid, the needle should be inserted through which of the following intercostal spaces?



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Pericardiocentesis is done by needle insertion through which of the following intercostal spaces?



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Which of the following statements is true regarding an emergent pericardiocentesis?



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Where is the needle placed when performing pericardiocentesis?



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A male presents with signs and symptoms of tamponade. He is hypotensive and in shock. To perform pericardiocentesis, where will the needle be inserted?



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You are performing an emergent percutaneous pericardiocentesis in a patient with tamponade. Since this is an emergency room and there is no time to call for an ultrasound; thus the procedure is performed blindly. After inserting the needle below the xiphoid and pointing towards the left shoulder, you aspirate the fluid. The first 5 ml of fluid you empty on the gauze and it immediately clots. What is the next step in the management of the patient?



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Where is the needle inserted for an emergent percutaneous pericardiocentesis?



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A 65-year old is prepped for a pericardiocentesis along the left sternocostal margin. As soon as the needle is inserted below the rib bright red blood is aspirated. A simultaneous ECHO shows that the needle is not in the heart. What is the most likely source of the bleeding?



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Pericardiocentesis - References

References

Chetrit M,Lipes J,Mardigyan V, A Practical Approach to Pericardiocentesis With Periprocedural Use of Ultrasound Training Initiative. The Canadian journal of cardiology. 2018 Sep     [PubMed]
Schusler R,Meyerson SL, Pericardial Disease Associated with Malignancy. Current cardiology reports. 2018 Aug 20     [PubMed]
Vilela EM,Ruivo C,Guerreiro CE,Silva MP,Ladeiras-Lopes R,Caeiro D,Morais GP,Primo J,Braga P,Ferreira N,Nunes JPL,Ribeiro VG, Computed tomography-guided pericardiocentesis: a systematic review concerning contemporary evidence and future perspectives. Therapeutic advances in cardiovascular disease. 2018 Aug 15     [PubMed]
Lekhakul A,Fenstad ER,Assawakawintip C,Pislaru SV,Ayalew AM,Maalouf JF,Nkomo VT,Thaden J,Oh JK,Sinak LJ,Kane GC, Incidence and Management of Hemopericardium: Impact of Changing Trends in Invasive Cardiology. Mayo Clinic proceedings. 2018 Aug     [PubMed]
Honasoge AP,Dubbs SB, Rapid Fire: Pericardial Effusion and Tamponade. Emergency medicine clinics of North America. 2018 Aug     [PubMed]
Narula J,Choudhury A,Sharma A, Pericardiocentesis can be nasty. Accidents do occur while     [PubMed]
Lekhakul A,Assawakawintip C,Fenstad ER,Pislaru SV,Thaden JJ,Sinak LJ,Kane GC, Safety and Outcome of Percutaneous Drainage of Pericardial Effusions in Patients with Cancer. The American journal of cardiology. 2018 Jun 22     [PubMed]
Cooper CA, Centesis studies in critical care. Critical care nursing clinics of North America. 2010 Mar     [PubMed]
Thomas F,Clemmer TP,Orme JF Jr, A survey of advanced trauma life support procedures being performed by physicians and nurses used on hospital aeromedical evacuation services. Aviation, space, and environmental medicine. 1985 Dec     [PubMed]
Alpert EA,Amit U,Guranda L,Mahagna R,Grossman SA,Bentancur A, Emergency department point-of-care ultrasonography improves time to pericardiocentesis for clinically significant effusions. Clinical and experimental emergency medicine. 2017 Sep     [PubMed]

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