Procedure: Pericardiocentesis

The Procedure

Today we tackle one of the most difficult and risky emergency procedures, but it’s one you probably already have the ultrasound and line skills to do well.

Pericardiocentesis

This procedure can have life-threatening complications; pericardiocentesis is best performed under ultrasound guidance by the most experienced operator available, ideally an interventional cardiologist.

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Instructions

Indications

Pericardial effusion (non-traumatic)

AND

Haemodynamic compromise or arrest

THIS PROCEDURE CAN HAVE LIFE-THREATENING COMPLICATIONS; PERICARDIOCENTESIS IS BEST PERFORMED UNDER ULTRASOUND GUIDANCE BUT THE MOST EXPERIENCE OPERATOR AVIALABLE, IDEALLY AN INTERVENTIONAL CARDIOLOGIST.

INCREASING PRELOAD WITH IV FLUIDS, MAY TEMPORAIZE AN UNSTABLE PATEINT UNTIL HELP IS AVAILABLE

Contraindications (ABSOLUTE/relative)

• Trauma (thoracotomy preferred)
• Aortic dissection (surgery required)
• Post-infarction rupture of the left ventricle (surgery required)
• Mixed shock (treat other potential cause before procedure)

Alternatives

• 500 ml IV crystalloid over 10 minutes
• Reverse coagulopathy
• Treat Anaemia (transfusion)
• Isoprenaline infusion (if no tachycardic response)
• Operative management (pericardial window)

Consent

CONSENT IS NOT REQUIRED

This is an emergency procedure to save a life.

Brief verbal discussion is recommended if the situation allows

Potential complications

• Failure (of insertion, drainage, or re-accumulation)
• Arrhythmia
• Cardiac puncture or laceration
• Vascular injury
• (internal mammary, intercostal, coronary artery, abdominal)
• Pneumothorax
• Air embolism
• Diaphragm or phrenic nerve injury
• Intra-abdominal injury (liver most likely)
• Infection (bacterial pericarditis)

The risks are affected by the approach and are minimised by using ultrasound to identify the largest and most accessible pocket of fluid. Ideally, we use a needle approach which will penetrate the pericardial sac but not the heart, even if we insert the needle too far.

If all positions demonstrate good view’s, we recommend the apical approach as the safest, (see discussion). The parasternal approach is excellent for our ED skill set but has more serious risks than the apical approach. It is particularly important to identify and avoid the internal mammary artery. The sub-xiphoid is the least amenable to a direct ultrasound approach and the long path to the heart increases failure risk and prohibits the use of our preferred linear high frequency US probe for procedures.

Specific risks by approach:

APICAL (SAFEST)

• Pneumothorax
• Intercostal vessel damage
• left ventricular puncture

PARASTERNAL

• (HIGH RISK OF CARDIAC OR VESSEL INJURY)
• Right atrial or ventricular puncture (less likely to self-seal than left heart)
• Internal mammary artery damage (located 1-3 cm lateral to the sternal border)
• Internal thoracic, proximal coronary artery, intercostals artery damage

SUBXIPHOID (HIGHEST RISK OF FAILURE)

• Failure (high risk due to long needle tract)
• Liver injury
• Right atrial / ventricular puncture (less likely to self-seal)

Infection control

• Standard precautions
• Aseptic non-touch technique
• PPE: Sterile gloves, sterile gown, sterile ultrasound cover, gel

Area

• Resuscitation bay

Staff

• Procedural clinician
• Procedural assistant
• Team leader
• Resuscitation team (prepared for cardiac arrest)

Equipment

CENTRAL LINE

• Use the set you are most familiar with
• Single or multiple lumen
• Long 15 cm needle required Sub-xiphoid

Or

PERICARDIOCENTESIS SET

• 18g needles (9cm long and 15cm long)
• Guidewire
• Dilator
• 8Fr pigtail catheter

UNFAMILIAR EQUIPMENT IS BEST AVOIDED IN AN EMERGENCY

STANDARD CENTRAL LINE SETS ARE FAMILIAR AND ADEQUATE

IF YOU ARE FAMILIAR WITH A SPECIFIC PERICARDIOCENTESIS SET USE IT

Additional:

• ULTRASOUND – linear array probe preferred

Positioning

LAY WITH BED INCLINED SEMI-RECUMBENT

(PREVENTS FLUID POOLING BEHIND THE HEART)

ROLL THE PATIENT TO POOL THE FLUID INTO THE BIGGEST TARGET

USE A PILLOW TO SUPPORT POSITION AS REQUIRED

SUBXIPHOID

• Semi-reclining position

PARASTERNAL OR APICAL

• Semi-reclining position
• Rolled onto on left side

Insertions points (adjusted to ultrasound findings):

APICAL

• 1 cm lateral to the apex beat
• Fifth to seventh intercostal space

SUBXIPHOID

• 1 cm 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% (if time allows)

Consider pain relief or anxiolytic:

• Ketamine IV 10-20mg (pain relief pre-procedure)
• Morphine IV 5-10mg (pain relief pre-procedure)
• Midazolam IV 1-2mg (anxiolytic pre-procedure)

Use reduced doses of medication

Medications may precipitate worsening haemodynamic status

Sequence (Ultrasound preparation)

Pre-assessment with the echo probe is recommended; Identify the easiest approach, with:

• GREATEST FLUID DEPTH
• CLOSE TO THE SURFACE
• NEEDLE TRACT AVOIDING HEART (IF POSSIBLE)

Sequence (Ultrasound guided technique)

ALL ULTRASOUND PROBES CAN VISUALISE A NEEDLE. THE LINEAR HIGH FREQUENCY PROBE WILL GIVE THE BEST RESOLUTION BUT ONLY PENETRATEs A FEW CENTIMETERS INTO TISSUE. DEEP EFFUSIONS WILL REQUIRE THE LOW FREQUNECY ABDOMINAL OR ECHO PROBE TO OBTAIN A VIEW OF THE EFFUSION.

REFLECTION OF SOUND WAVES BACK TO THE PROBE IS NEEDED TO VISUALISE THE NEEDLE WITH ULTRASOUND. STEEP NEEDLE ANGLES RESULT IN NO NEEDLE VISUALISATION ON THE SCREEN. YOU MAY STILL SEE THE NEEDLE MOVE TISSUES.

IF UNABLE TO VISUALISE YOUR NEEDLE (EXPECTED FOR SUB-XIPHOID APPROACH) YOU CAN PROCEED IN A PRE-DETERMINED TRACT FROM YOU MARKED POINT USING AN EXPECTED DEPTH OF EFFUSION FROM INITIAL ULTRASOUND ASSESSMENT.

• Select the best approach with ultrasound assessment and mark site
• Do not change patient position (altering the position of the heart)
• Select required needle length (9 cm or 15 cm)
• Anaesthetise with 1% lignocaine and consider analgesia and sedation agents
• Avoid the upper half of rib spaces (avoiding neurovascular bundle)
• Insert needle next to the ultrasound probe marker
• Attempt to visualise needle from skin to pericardial sac with gentle aspiration as you advance
• In plane or out of plane approach can be used according to clinician preference
• Once the pericardial space is entered, aspirate 20-40 ml of fluid
• Pass the guidewire 20-30 cm into the pericardial sac, or until resistance is met
• Confirm wire in pericardial space in multiple ultrasound planes
• Insert drain over wire using Seldinger technique
• Remove as much fluid as possible with a syringe than cap your line.
• 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 pericardiocentesis 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
• Leave line capped, but assessable for re-drainage as required

Sequence (Blind Sub-Xiphoid technique)

THIS APPROACH HAS LOW SUCCESS AND HIGH COMPLICATION RATE (15-20%)

IT IS ONLY USED IF ULTRASOUND NOT AVAILABLE OR IN CARDIAC ARREST

• Attach a 15 cm 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 40 ml, then place the pigtail drain using Seldinger technique

Sequence (Confirming wire position)

CONFIRMING POSITION IS A KEY STAGE IN THE PROCEDURE, ESPECIALLY IF BLOOD IS ASPIRATED. IF BLOOD IS ASPIRATED, WE NEED TO EXCLUDE PUNTURE OF A VENTRICLE PRIOR TO DILATION AND LINE PLACEMENT.

ANY NEEDLE PUNTURE OF THE HEART WILL USUALLY SELF SEAL, HOWEVER ONCE DILATED ANY CARDIAC PUNTURE IS LIKELY TO REQUIRE CARDIOTHORACIC SURGERY.

WE RECOMMED CONFIRMING GUIDWIRE POSITION WITH US PRIOR TO DRAIN INSTERTION IN THE SAME WAS AS WE WOULD FOR A CENTRAL LINE.

ULTRASOUND

• Pass the guidewire 20-30 cm
• If resistance is felt prior to this stop
• Acute effusions may not allow 20 cm insertion
• The wire should curl around pericardium
• This can be visualised with ultrasound

WE BRIEFLY DISCUSS THE OTHER METHODS THAT CAN BE USED TO ASSESS WIRE OR LINE POSITION:

FLUID TYPE (useful)

• Blood indicates pericardial blood or pericardial puncture
• Serous fluid indicated pericardial or pleural effusion

HAEMODYNAMICS (useful)

• Assess response to aspiration
• Removing pericardial fluid will improve blood pressure
• Removing ventricular blood will worsen blood pressure

CLOTTING (less reliable)

• Aspirated cardiac blood will clot in a specimen pot
• Pericardial blood will usually not clot
• (fibrinolytic properties of pericardium)

ECG MONITORING (unlikely to be available)

• Place an ECG electrode on the pericardiocentesis needle with a crocodile clip
• Proceed with the insertion of the needle
• The lead should record a trace which looks like a normal surface ECG trace
• If the needle tip touches the myocardium the trace will show immediate ST elevation
• Insert the wire whilst aspirating fluid without ST elevation of ECG lead

AGGITATED SALINE (high risk for changing needle position)

• Used after needle aspiration prior to dilation for the line.
• Fill a 10 syringe with saline
• Pull back 2 ml of air on a second 10 ml syringe
• Connect the 10ml syringes to a three-way stop cock
• Rapidly inject saline between the syringes to mix air and saline (agitation)
• Inject it into the pericardial space using extension tubing (minimising needle movement)
• Monitor the entrance of the agitated saline into the pericardial space with ultrasound
• A brightly echogenic stream in the pericardial space confirms position

Post-procedure care

ONGOING CARE

• Repeat ultrasound to confirm aspiration
• Continue cardiac monitoring
• Chest X-ray (exclude pneumothorax)
• Analgesia for pleuritic pain (consider PCA)
• Discuss with cardiology
• Discuss haemorrhagic effusions with cardiothoracic surgery
• Document insertion with depth, complications, fixation, and function
• Expect cardiology to remove drain within 24hours

TESTING OF SAMPLE

• (cell count vacutainer, culture bottles, specimen pot)
• Cell count and differential
• Gram Stain and Culture (aerobic and anaerobic)
• Biochem (pH, protein, albumin, glucose, LDH)
• Microbiology (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 40 ml usually results in return of spontaneous circulation or hemodynamic improvement
• Haemorrhagic tamponade will reaccumulate and may require cardiothoracic operative management
• Consider acute lymphoblastic leukaemia in young people with unexpected effusion
• Post CABG avoid parasternal path in case of internal mammary grafts

Discussion

Stable patients with pericardial effusion can be admitted, assessed by cardiology, and receive pericardiocentesis in the catheter laboratory if required.

We only perform Emergency Department Pericardiocentesis for patients in cardiac tamponade meaning a shocked state with a pericardial effusion. Additional ultrasound features are not required but support the diagnosis (diastolic collapse of RV, a collapsed LV with walls touch in systolic, indicating 100% ejection, and a distended IVC).

Initially, gather equipment and attempt to temporise the patient until specialist help arrives. 500 ml of IV crystalloid may increase cardiac output. Watch for worsening hypoxia (pulmonary oedema) or falling blood pressure due to ventricular interdependence (large RV pushing into the LV) which should prompt you to cease the bolus. We should also correct coagulopathy, anaemia and consider chronotropic agents (isoprenaline) in the rare cases where the patient has an inappropriately slow heart rate for any reason (beta blockade).

If required, ED Pericardiocentesis is complex and high risk. Keep the procedure as simple as possible by using familiar techniques and equipment. Perform only when essential. We recommend using a normal central line with the high frequency US probe used for standard procedures.

Emergency department pericardiocentesis should be guided by ultrasound (complication rate 2%) with visualisation of the pericardial effusion and intended needle approach, ideally with ultrasound visualisation of needle tip from skin to aspiration. Blind subxiphoid pericardiocentesis has a high complication rate (17.5%) and should be avoided outside arrest situations or unless ultrasound is unavailable.

We recommend aspiration using the ultrasound window that demonstrates the deepest area of fluid, closest to the skin with the best range of angles of approach and clear access, ideally avoiding the heart. All approaches contain risk which is best minimised by visualising needle tip on ultrasound from skin to aspiration.

If all windows demonstrate good views of the pericardial effusion, we recommend approaching the left ventricular wall via the apical approach. While both the parasternal and apical approaches provide excellent views for aspiration with the linear probe and our good for our standard ED skill set, the parasternal view is more dangerous with increased risks of bleeding from right ventricular puncture (thin walled, less able to self-seal) and accidental coronary or internal thoracic artery puncture. To aspirate safely in the parasternal window, you must have the ultrasound skills to confidently identify and avoid the internal mammary artery.

It is not possible to visualise an aspirating needle under US guidance when the effusion is deep (Sub-Xiphoid approach). A steep needle does not reflect many sound waves back to the transducer and will not be seen on the ultrasound screen. It may still be possible to see tissue movement caused by the needle passage.

When using phased array probe or curvilinear probe for a deep effusion (Sub-Xiphoid) it may be necessary to proceed without visualising the needle using an US guided insertion point, measured depth, and estimated angle of approach. As the pericardium is a tough fibrous capsule that may be indented by the needle, you may expect to have to insert the needle around 1-2cm beyond the visualised depth.

We recommended aspirating 20-40 ml of pericardial fluid via needle aspiration prior to inserting the drain. This amount of fluid should be sufficient to improve stability and may be sufficient to temporise the patient if you fail in drain placement. Leaving some effusion present while inserting your drain leaves a greater margin for error and increases safety. 

Traditionally it is recommended the guidewire is inserted > 20 cm to ensure it is coiling around the heart and moving freely in the effusion. Our expert reviewers inform us that this may not be possible for rapidly accumulating smaller effusions where the wire may “hold up” after a few centimetres. Care should be taken not to force the wire which may kink leading to failure to pass the drain.

Confirming position of the guide wire in the pericardium is a key stage in the procedure. We must ensure we dilate and place our drain in the correct place. This is especially true when blood is aspirated, where we should exclude a ventricular puncture and the serious risk of placing the drain inside the heart. We recommend confirming wire placement with US in multiple views while considering the other methods listed above (confirming position) as adjuncts. If using agitated saline, it is important to anchor the needle in place throughout the procedure, we have noted that the needle tip can be easily displaced whilst agitating and injecting.

Pericardial tamponade second to trauma is a relative contraindication for a pericardial drain. While pericardial blood has a tendency not to clot due to local fibrinolytic effects and may be drainable, traumatic bleeding requires surgical thoracotomy. A pericardial drain might stabilize for vital minutes to get a patient to theatre, but a drain is not a definitive solution. If the patient arrests in ED following traumatic cardiac tamponade, thoracotomy in ED is indicated.

Pericardial tamponade second to aortic dissection or ventricular rupture are also relative contraindications. Again, this pathology requires thoracotomy and surgical intervention. However, 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 on route to theatre.

References

• Alerhand S, Adrian RJ, Long B, Avila J. Pericardial tamponade: A comprehensive emergency medicine and echocardiography review. Am J Emerg Med. 2022 Aug;58:159-174
• Yehuda A et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2015 Nov 7;36(42):2921-2964.
• Roberts JR, Hedges JR (eds), Clinical Procedures in Emergency Medicine 7th Edition, WB Saunders Company
• UpToDate (2020): Heffner A, Emergency pericardiocentesis
• Osman A, Wan Chuan T, Ab Rahman J, Via G, Tavazzi G. Ultrasound-guided pericardiocentesis: a novel parasternal approach. Eur J Emerg Med. 2018 Oct;25(5):322-327
• Sinnaeve PR, Adriaenssens T. A contemporary look at pericardiocentesis. Trends Cardiovasc Med. 2019 Oct;29(7):375-383.
• Maggiolini S, De Carlini CC, Imazio M. Evolution of the pericardiocentesis technique. J Cardiovasc Med (Hagerstown). 2018 Jun;19(6):267-273
• Petri N, Ertel B, Gassenmaier T, Lengenfelder B, Bley TA, Voelker W. “Blind” pericardiocentesis: A comparison of different puncture directions. Catheter Cardiovasc Interv. 2018 Nov 1;92(5):E327-E332

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