Circulation - Pericardiocentesis

This procedure can have life-threatening complications and is best performed under ultrasound guidance by the most experienced operator available, who may be a cardiologist.

Indications

Pericardial effusion (non-traumatic)

and

Haemodynamic compromise or arrest

Contraindications (Absolute in bold)

Trauma (thoracotomy preferred)

Aortic dissection

Post-infarction rupture of the left ventricle

Alternatives

IV crystalloid (increasing preload as a temporising measure)

Operative treatment (pericardial window)

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

Potential complications

Failure (of insertion, drainage or re-accumulation)

Arrhythmia

Cardiac puncture

Vascular injury (internal mammary, intercostal artery, LAD artery)

Hemopneumothorax or pericardium

Diaphragm or phrenic nerve injury

Intra-abdominal injury (liver most likely)

Left ventricular dysfunction after drainage (acute heart failure)

Infection (bacterial pericarditis)

The follow risks are increased depending on approach:

Apical

Pneumothorax, ventricular puncture

Subxiphoid (recommended in arrest or when ultrasound not available)

Intra-abdominal injury (liver most likely), right atrial puncture (unlikely to self-seal)

Parasternal (needle <1 cm lateral to the sternal border to avoid internal mammary artery)

Vascular injury (internal thoracic or LAD artery)

Procedural hygiene

Standard precautions

Aseptic non-touch technique

PPE: Sterile gloves, sterile gown, sterile ultrasound cover and gel

Area

Resuscitation bay

Staff

Procedural clinician and assistant

Additional clinician dedicated to monitoring

Equipment (may be contained in a pericardiocentesis set)

Ultrasound with phased array probe (or curvilinear probe if subxiphoid)

10ml syringe and 25g needle (for local anaesthetic)

18g spinal needles (9cm long and 15cm long) with 60ml syringe

Guidewire

Dilator

8Fr pigtail catheter

Three-way stopcock

10ml syringe and 10ml saline (agitated saline test)

Underwater sealed drainage

Positioning

Subxiphoid approach: semi-reclining position with head slightly elevated

Parasternal or apical approach: patient supine then rolled onto on left side (if possible)

Approximate insertions points (adjusted to ultrasound findings)

Apical: The apical insertion site is 1cm lateral to the apex beat within the fifth to seventh intercostal space

Subxiphoid: 1cm inferior to the left xiphoid border

Parasternal: 1cm lateral to the sternal border over superior border of the fifth or sixth rib

Medication

Supplemental oxygen throughout procedure

10 ml lignocaine 1%

Consider procedural sedation (covered separately), or

Ketamine IV 10-20mg (pain relief pre-procedure adjusted to haemodynamic status)

Morphine IV 1-2mg (opioid pain relief pre-procedure adjusted to haemodynamic status)

Midazolam IV 1-2mg (anxiolytic pre-procedure adjusted to haemodynamic status)

Sequence (ultrasound approach)

Evaluate the pericardial effusion with ultrasound in parasternal, apical and subxiphoid views

Identify the approach for aspiration as the largest area of the effusion with the best view

Position patient, mark site and avoid changing position (altering the position of the heart)

Confirm the depth of the effusion on ultrasound and select 18g needle (length 9cm or 15 cm)

Anaesthetise the selected area with 1% lignocaine and consider sedation agents

Avoid the upper half of rib spaces and the area 3-5cm lateral to sternum (avoiding arteries)

Attach the needle to a 60ml syringe and insert needle next to the probe marker at an angle of 45 degrees

Visualise the needle (in plane ultrasound approach) from skin to pericardial sac with gentle aspiration as you advance

Once the pericardial space is entered, aspirate 30-50ml of fluid

If non-bloody fluid aspirated, ventricular puncture has been excluded

If blood aspirated, confirm placement in pericardial space with agitated saline test (see below)

Place guidewire and insert pigtail drain using Seldinger technique

Attach a three-way tap and remove fluid assessing for improvement in haemodynamics

Place a ‘stay’ suture to close the skin incision at the site of insertion

The ends of this suture are left long, then wrapped tightly around the chest tube and tied securely

A split gauze dressing is placed around the catheter (to protect skin from pressure)

Dress with water-permeable transparent dressing so the insertion site is visible

Cap line or consider attaching to an underwater sealed drain

Sequence (confirming position with agitated saline test)

Fill one 10ml syringe with saline and a second with air

Connect the 10ml syringes to a three-way stop cock

Rapidly inject saline between the syringes and then inject it into the pericardial space

Monitor the entrance of the agitated saline into the pericardial space with ultrasound

A brightly echogenic stream in the pericardial space confirms position

If you are unable to confirm position in the pericardial space and have aspirated blood, there is a risk you have punctured the ventricle, and dilation and catheter placement should not proceed. You should not dilate the tract and or place a catheter. Remove the needle and reattempt insertion.

Sequence (blind technique)

This approach has low success and a high complication rate. It is only used if ultrasound is not available.

Attach a 15cm spinal needle to a 60ml syringe

Insert needle 1cm inferior to the left xiphoid border

Aim towards the left shoulder at a 30 degree angle to the skin

Advance the needle slowly with negative pressure on the syringe

If no fluid is aspirated, withdraw the needle, and redirect it more posteriorly

If no fluid is aspirated, withdraw the needle, and repeat, redirecting the needle anticlockwise 20 degrees

If no fluid is aspirated, withdraw the needle, redirecting further anticlockwise (until aiming at right neck)

When fluid is aspirated, withdraw 50ml, then place the pigtail drain using Seldinger technique

Post-procedure care

Ongoing care

Repeat ultrasound evaluation of pericardial effusion

Continue continuous cardiac monitoring for 24 hours (cardiac dysfunction, re-accumulation)

Chest X-ray (confirm position, exclude pneumothorax, exclude free air under diaphragm)

Check function of underwater sealed drain if placed (output, oscillation, bubbling)

Drain observations (output, oscillation, leaks) 30 minutely until stable then hourly for four hours

Analgesia (oral, or IV considering PCA) to allow deep breathing and coughing

Discuss with cardiologist (and cardiothoracic team if blood aspirated)

Document insertion with depth, complications, fixation, and function

Laboratory testing of sample: (cell count vacutainer, culture bottles, specimen pot)

Cell count and differential

Gram Stain and Culture (aerobic and anaerobic)

Biochemical analysis (pH, protein, albumin, glucose, LDH)

Microbiology (admitting team to consider PCR testing)

Cytology

Tips

Respiratory distress is a common presenting feature of cardiac tamponade

Avoid positive pressure ventilation which can reduce right ventricular filling further

Coagulopathy should always be considered and simultaneously treated

A pericardial effusion 10-20 mm deep is likely to contain 250-500 mL of fluid

Removal of 30 to 50 mL usually results in return of spontaneous circulation or hemodynamic improvement

Haemorrhagic tamponade will reaccumulate and requires cardiothoracic operative management

Discussion

Pericardiocentesis in the emergency department is indicated for non-traumatic pericardial effusion with a clinical picture of obstructive shock (tachycardia, hypotension, raised JVP). Stable patients with pericardial effusion can be admitted, assessed by cardiology and receive pericardiocentesis on the ward if required.

The ultrasound features that support tamponade are diastolic collapse of RV, a collapsed LV (walls touch in systolic, indicating 100% ejection) and a distended IVC.

We recommend aspiration using the ultrasound window that demonstrates the deepest area of fluid with the best view. All three approaches contain risk which is best minimised by visualising needle tip on ultrasound from skin to aspiration. It is important to avoid the internal mammary artery (3 to 5 cm from either parasternal border) and the intercostal arteries (inferior border of each rib).

Emergency department pericardiocentesis should be guided by dynamic ultrasound with visualisation of the needle tip from skin to aspiration. Blind pericardiocentesis has a high complication rate and should be avoided outside arrest or peri-arrest situations where an ultrasound is unavailable

Needle insertion is typically next to the probe marker using an in plane approach. Usually the phased array probe or curvilinear probe is used, however if the effusion is close to the surface, the high-frequency transverse probe can be used to improve visualisation of the needle and local arteries.

Traumatic pericardial tamponade or tamponade second to aortic dissection or post MI left ventricle are relative contraindications. Pericardial blood has a tendency not to clot due to local fibrinolytic effects and may be drainable, however bleeding is unlikely to be temporised by a drain and requires surgery. Thoracotomy in theatre is preferred.

If the patient arrests in ED following traumatic cardiac tamponade thoracotomy in ED is indicated. For the unstable or arrested aortic dissection patient with ultrasound evidence of tamponade, controlled pericardial drainage of small amounts of blood can be attempted to temporarily stabilise the patient and maintain systolic blood pressure of 90 mmHg.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Greater Sydney Area Helicopter Emergency Service

CareFlight

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Yehuda A et al (2015): ESC Guidelines for the Diagnosis and Management of Pericardial Diseases. Practice Guideline Eur Heart J 2015 Nov 7;36(42):2921-2964. doi: 10.1093/eurheartj/ehv318. Epub 2015 Aug 29.

Roberts JR, Hedges JR (eds), Clinical Procedures in Emergency Medicine 7th Edition, WB Saunders Company

Dunn R et al (eds), The Emergency Medicine Manual: Venom Publishing (Online April 2019)

UpToDate (2020): Heffner A, Emergency pericardiocentesis

Osman A et al (2018): Ultrasound-guided Pericardiocentesis: A Novel Parasternal Approach. Eur J Emerg Med 2018 Oct;25(5):322-327.

Sinnaeve P et al (2019): A Contemporary Look at Pericardiocentesis. Trends Cardiovasc Med 2019 Oct;29(7):375-383

Maggiolini S et al (2018): Evolution of the Pericardiocentesis Technique J Cardiovasc Med 2018 Jun;19(6):267-273.

Petri N et al (2018): "Blind" pericardiocentesis: A comparison of different puncture directions. Catheter Cardiovasc Interv. 2018;92(5):E327. Epub 2018 May 8.

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