Procedure: Pericardiocentesis

The Procedure

Hello again from the Emergency Procedures team.

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.

Detailed written instructions and explanation are available in our Free App (iOS and Android). This video is hot off the press and we want your help improving it. Drop us a line with any suggestions

So, without further ado…here is the video

The rationale…

Which patient should receive an emergency department pericardiocentesis?

We only perform for cardiac tamponade meaning a shocked state with a pericardial effusion.

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

Are there any contraindications?

In mixed shock (e.g. sepsis with a pericardial effusion) you should treat the other causes of shock first before considering pericardial drainage.

In suspected aortic dissection, ventricular rupture or traumatic pericardial effusion, thoracotomy is required and pericardiocentesis is relatively contraindicated. Peri-arrest patients in these groups may benefit from controlled pericardial drainage to stabilise the patient on route to theatre.  

Do I need to use a special pericardiocentesis line?

Pericardiocentesis is rarely performed, complex and high risk. Our principle has been to keep it as simple as possible by using familiar techniques and equipment. We recommend performing only with a familiar line (e.g. normal central line) and the high frequency US probe (used for all Seldinger procedures).

If you have a special pericardiocentesis kit and you have practised with it, it may be a good choice (e.g. one lumen, specially designed bevel, stiffer wire). However, an emergency procedure with life threatening complications is not the time to try something new.

What happens if my needle punctures the heart?

Ideally, we find an ultrasound view of the pericardium which allows us to insert our needle in a plane that does not intersect the heart. We are looking for good pericardial fluid windows rather than good heart views.

You may not find this ideal window and your needle tract may be towards the heart. Additionally, the pericardial sac is fibrous and indents towards the moving heart before it is pierced. Cardiac puncture with your needle is a real risk and a reason this procedure is only performed when urgently required.

Most needle punctures of the heart will self-seal, however if you dilate the heart and place your line this will require surgery and is life threatening. Confirming your guidewire placement before dilation is key.

How do I confirm guidewire placement before I dilate and place my line?

Pass the guidewire 20-30 cm or until you meet resistance, which can happen after only a few centimetres in an acute pericardial effusion. It should coil around the heart inside the pericardium. Confirm the guidewire is in the pericardial space in multiple ultrasound views before dilating and placing your line.

We discuss other methods in the written guide:

• TYPE OF FLUID ASPIRATED
• PATIENT HAEMODYNAMIC RESPONSE TO ASPIRATION
• CLOTTING OF ASPIRATED BLOOD
• ECG MONITORING
• MOBILE X-RAY AT BEDSIDE
• AGGITATED SALINE

All methods have advantages and disadvantages, there is no perfect way to guarantee line position. Another reason why this is a risky procedure, only performed for tamponade.

I really want to avoid this procedure if possible…Can I just temporize with some IV fluids until a cardiologist arrives?

Yes, it’s a good idea to try this. Increasing preload with a 500 ml crystalloid bolus may increase blood pressure and buy you some time.

Remain aware that preload is already high in tamponade and fluid may result 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

I’ve spotted an improvement that could be made to your video and guide…..

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The App