Pericardiocentesis

Last updated: January 10, 2023

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Pericardiocentesis is a procedure that involves removing pericardial fluid for diagnostic evaluation or to treat pericardial effusions and/or cardiac tamponade. A spinal needle is attached to a syringe and inserted into the pericardial sac to aspirate blood or fluid. A temporary drain may be placed during the procedure if significant pericardial fluid drainage is required. Multiple approaches (subxiphoid, apical, and parasternal) may be used to perform pericardiocentesis, generally with ultrasound guidance. There are no absolute contraindications to pericardiocentesis. Complications include dysrhythmias, pneumothorax, pneumopericardium, and pericardial decompression syndrome.

Hemopericardium from a penetrating chest injury requires urgent surgical management, however, pericardiocentesis may be used as a temporizing measure if surgery is not immediately possible. [4]

We list the most important contraindications. The selection is not exhaustive.

General principles

Pericardiocentesis approach [3]

  • Subxiphoid
    • Entry point: 1 cm inferior to the left xiphocostal angle
    • Trajectory: Position the needle at a 30° angle to the skin and advance toward the left shoulder.
  • Apical
    • Entry point: the intercostal space inferior and 1 cm lateral to the cardiac apex
    • Trajectory: Advance the needle over the rib toward the right shoulder.
  • Parasternal

The subxiphoid approach is preferred for patients in cardiac arrest or if ultrasound is unavailable. [3]

Emergency pericardiocentesis may be performed with minimal equipment, however, additional equipment is required for temporary drain placement. [3]

Minimum equipment

Agitated saline apparatus

Temporary pericardial drain equipment

Pericardial puncture [3]

  1. Attach a large (16–18-gauge, 6 inch) spinal needle to a syringe.
  2. Follow the selected approach for pericardiocentesis under ultrasound guidance.
  3. Maintain negative pressure on the syringe and advance until fluid returns.
  4. Remove the syringe and attach the agitated saline apparatus.
  5. Confirm pericardial needle placement by injecting agitated saline under ultrasound guidance.
  6. Follow the diagnostic pericardiocentesis steps or therapeutic pericardiocentesis steps as needed.

Diagnostic pericardiocentesis steps [3]

  1. Perform pericardial puncture steps and confirm proper needle position.
  2. Aspirate enough fluid for pericardial fluid analysis.
  3. Once fluid is obtained, remove the needle and place an occlusive dressing.

Therapeutic pericardiocentesis steps [3]

Pericardial drain placement is an optional step for patients with a high risk of recurrence.

  1. Perform pericardial puncture steps and confirm proper needle position.
  2. For cardiac tamponade, aspirate enough fluid to relieve obstructive shock using an appropriately sized syringe. [5][6]
  3. If pericardial drain placement is desired, use a Seldinger technique as follows:
    1. Advance the guidewire through the needle into the pericardial sac.
    2. Make a small incision at the site of entry.
    3. Use a vascular dilator to dilate the tissue tract.
    4. Remove the dilator and advance the pigtail catheter.
    5. Secure the catheter with a suture and apply a sterile dressing.
    6. Connect the catheter to a water seal to drain by gravity.
  • CXR obtained
  • Patient admitted for postprocedural monitoring [7]
  • Sample sent for pericardial fluid analysis (if desired)
  • Procedure documented
  • Ultrasound repeated 24 hours postprocedure to assess for recurrent effusion

Obtain an erect chest x-ray after pericardiocentesis to exclude iatrogenic pneumothorax and pneumopericardium! [8]

The risk of complications is greater if a blind technique is used. [4][10]

We list the most important complications. The selection is not exhaustive.

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  2. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
  3. Roberts JR. Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care. Elsevier ; 2018
  4. American College of Surgeons and the Committee on Trauma. ATLS Advanced Trauma Life Support. American College of Surgeons ; 2018
  5. Muzyk AJ, Fowler JA, Norwood DK, Chilipko A. Role of α2-Agonists in the Treatment of Acute Alcohol Withdrawal. Ann Pharmacother. 2011; 45 (5): p.649-657. doi: 10.1345/aph.1p575 . | Open in Read by QxMD
  6. Pradhan R, Okabe T, Yoshida K, Angouras DC, DeCaro MV, Marhefka GD. Patient characteristics and predictors of mortality associated with pericardial decompression syndrome: a comprehensive analysis of published cases. European Heart Journal: Acute Cardiovascular Care. 2014; 4 (2): p.113-120. doi: 10.1177/2048872614547975 . | Open in Read by QxMD
  7. Finnel L. Tintinalli's Emergency Medicine Manual, Eighth Edition. McGraw Hill Professional ; 2017
  8. Shah K, Mason C. Essential Emergency Procedures. Lippincott Williams & Wilkins ; 2007
  9. Prabhakar Y, Goyal A, Khalid N, et al. Pericardial decompression syndrome: A comprehensive review. World Journal of Cardiology. 2019; 11 (12): p.282-291. doi: 10.4330/wjc.v11.i12.282 . | Open in Read by QxMD
  10. Petri N, Ertel B, Gassenmaier T, Lengenfelder B, Bley TA, Voelker W. “Blind” pericardiocentesis: A comparison of different puncture directions. Catheter Cardiovasc Interv. 2018; 92 (5): p.E327-E332. doi: 10.1002/ccd.27601 . | Open in Read by QxMD

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