PERICARDIOCENTESIS

Definition
 Pericardiocentesis is the removal of fluid from the
pericardial space surrounding the heart. The fluid is
usually aspirated with a needle and syringe.

 This may be performed for diagnosis, to obtain

pericardial fluid; to relieve a pericardial effusion and
improve cardiac output; or as a lifesaving measure to
relieve a cardiac tamponade.
 Cardiac Tamponade
 Cardiac tamponade is a clinical syndrome caused by
the accumulation of fluid in the pericardial space,
resulting in reduced ventricular filling and subsequent
hemodynamic compromise.

 Beck's triad of muffled heart sounds, hypotension,

and jugular venous distention is associated with
cardiac tamponade. Almost all patients with cardiac
tamponade will have at least one of these signs.
Diagnostic Finding
 Indication Contraindication

 Emergent:  Small, loculated, or

posteriorly located effusions
The presence of life threatening
hemodynamic changes in a in a stable patient
patient with suspected cardiac
tamponade
 Traumatic pericardial efusion
with unstable vital sign
 Nonemergent:
 Myocardial rupture
The aspiration of pericardial
fluid in hemodynamically stable  Aortic dissection
patient for diagnostic or
palliative reasons, performed  Severe bleeding disorder
under USG, CT, or flouroscopic
visualization
 Equipment
 Code cart and resucitation
equipment
 Hemodynamic monitoring
device
 Ultrasound machine
 ECG machine
 18 G spinal needle
 Three way stopcock
 20 ml syringe
 Antibacterial Skin Cleanser
 Wire with alligator clips
 Sterile gloves
 Patient Preparation
 Explain the procedure to the
patient and/or their
representative.

 If possible, place the patient

semirecumbent at a 30 to 45
degree angle.. The supine
position is an acceptable
alternative.

 Assess the patient for any

mediastinal shift.

 Apply the cardiac monitor, pulse

oximeter, BP monitor and
supplemental oxygen to the
patient.

 Insert a nasogastric tube to

decompress the stomach..
1. Identify the anatomic
landmarks. The needle
can be inserted at
numerous sites. These
include the following:
 below the xiphoid process,
at the right sternocostal
margin, at the left
sternocostal margin
(subxiphoid approach)
 In the left or right fifth
intercostal space
parasternally (parasternal
approach)
 in the left fifth intercostal
space at the midclavicular
line (apical approach).
2. Apply povidone iodine solution to the xiphoid and
subxiphoid areas and allow it to dry.

3. If time allows, apply sterile drapes to delineate a sterile

surgical field. Reidentify the anatomic landmarks. Put on
sterile gloves and mask, dress in a sterile gown.

4. Infiltrate local anesthetic solution at the chosen site by first

creating a skin wheal and then infiltrating the subcutaneous
and deeper tissues.

5. Puncture the skin using a No. 11 blade scalpel at the

chosen site

6. Connect a 20 or 60 ml syringe to the spinal needle, aspirate

5 ml of normal saline onto the syringe.
 Blind Insertion Technique

1. Grasp the syringe with the

dominant hand. Insert the
spinal needle (16-18 G)
through the skin at a 45
degree angle to the
midsagittal plane and at a
45 degree angle to the
abdominal wall.
2. Advance the spinal needle 4
to 5 cm while applying
negative pressure to the
syringe until a return of fluid
is visualized, cardiac
pulsations are felt, or an
abrupt change in the ECG
waveform is noted.
Notes:
 If the ECG shows an injury
pattern, slowly withdraw the
needle (1-2mm) until the
pattern returns to normal
 While advancing the needle,
inject 0.25 to 0.50 mL of
saline occasionally to ensure
that the needle remains
patent.
6. When the pericardial space is entered and fluid is
aspirated, there should be a marked improvement in the
patient's clinical status. Withdraw as much fluid as possible.
When the syringe is filled with fluid, stop withdrawing the
plunger. Replace the syringe with a new one.
7. An alternative setup to replacing syringes is using a 3-way
stopcock and intravenous tubing, which allows the
physician to aspirate pericardial fluid into the syringe and
eject the fluid into a basin or collection bag.
8. As pericardial fluid is aspirated, the needle may move
closer to the heart, and if an injury pattern appears on the
ECG waveform, then the needle should be slowly
withdrawn.
9. Remove the needle when fluid can no longer be aspirated.
 ECG-Monitored Technique

 The purpose of ECG monitoring is to prevent accidental

ventricular puncture with the spinal needle.
 Attach one alligator clip to the base of the spinal needle and
the other to the V1 lead of the ECG machine. The V1 lead
will serve as an active electrode based at the tip of the
spinal needle.
 As the spinal needle is advanced, an injury pattern noted by
ST-segment elevation will be seen if the myocardium is
contacted or penetrated by the spinal needle.
 If an injury pattern or premature ventricular complexes are
seen on the ECG monitor, withdraw the needle in 1 to 2 mm
increments until the injury pattern disappears.
 Seldinger Technique

 An indwelling catheter may be placed in the pericardial

cavity to drain the pericardial fluid

 This may be done in cases of medical or traumatic

pericardial effusions, since the pericardial fluid often
reaccumulates. An indwelling catheter allows
intermittent drainage of pericardial fluid without the
potential complications associated with repeated
needle sticks from a pericardiocentesis.
 Ultrasound-Guided Technique

 The ultrasound is used to localize the area of the

largest effusion. The point of needle insertion will be
where the pericardial fluid is maximal.

 The transducer is used to locate the area of largest

effusion and the needle is inserted suitably close by
and advanced toward the maximal effusion. Proper
needle placement can be further confirmed by injecting
saline that has been shaken to produce bubbles. The
bubbles will show well on the ultrasound.
 Confirmation
 Clotting: intracardiac blood forms a clot, whereas
pericardial aspirate should not form a clot.

 Hematocrit or hemoglobin measurement: the

pericardial aspirate should have a lower hemoglobin
concentration than the patient’s peripheral blood.
 ASSESSMENT

 a significant improvement in the patient's clinical status

should be observed after successful drainage of the
pericardial space.

 The patient's blood pressure and cardiac output should

increase while intracardiac pressure and
intrapericardial pressure decrease.

 Obtain a chest radiograph after the procedure to rule

out a hemothorax and/or pneumothorax.
 AFTERCARE
 Secure the catheter with sutures to the skin and check for
stability.
 Monitor patients for reaccumulation of pericardial fluid and
for hemodynamic instability.
 If fluid reaccumulates, the procedure should be repeated or
the stopcock opened and the pericardial space reaspirated.
 Flush with sterile saline after each aspiration to maintain the
patency of the catheter.
 Consult a Thoracic Surgeon if purulent fluid is aspirated in
medical patients.
 All patients must be admitted to an intensive care unit for
further monitoring, evaluation, and treatment.
 COMPLICATION
 Aspiration of ventricular blood instead of pericardial blood
 Laceration of ventricular epicardium/myocardium
 Laceration of coronary artery or vein
 New hemopericardium
 Ventricular fibrillation
 Pneumotorax
 Puncture of great vessels with worsening of pericardial tamponade
 Puncture of esophagus with subsequent mediastinitis
 Puncture of peritoneum with subsequent peritonitis or false
positive aspirate