Pericardiocentesis

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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. It may be performed in both children and adults.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.

• Diagnostic pericardiocentesis: sampling of pericardial effusion for pericardial fluid analysis to determine underlying etiology
• Therapeutic pericardiocentesis: removal of pericardial fluid to relieve symptoms of pericardial effusion and/or treat cardiac tamponade

• Diagnostic pericardiocentesis ^[2]
  • Pericardial effusion of unclear etiology
  • Need for tests that guide management: e.g., cytology, culture and sensitivity
• Therapeutic pericardiocentesis ^[2]
  • Hemodynamically unstable patients with cardiac tamponade
  • Symptom relief in select patients: e.g., large chronic effusions
  • Purulent pericarditis in patients who cannot undergo surgery. ^[3]

• Absolute: none
• Relative
  • Coagulopathy
  • Implanted cardiac device (e.g., cardiac pacemaker, prosthetic heart valve)
  • Alternative procedure preferred
  • Previous thoracoabdominal surgery
  • Inability to visualize the effusion with ultrasound during the procedure

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. ^[5]

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

• Pericardiocentesis can be performed with or without placement of an indwelling catheter (pericardial drain).
• Guidance with imaging is preferred, e.g., using POCUS, CT, or fluoroscopy.
• A blind technique can be performed if ultrasound is unavailable in patients with cardiac arrest or peri-arrest arrhythmias.
• Agitated saline can be used to confirm needle positioning within the pericardial space.
• ECG leads attached to the needle to help confirm positioning if POCUS is unavailable.

There are three main approaches to pericardiocentesis. See “Focused cardiac ultrasound” for details on the POCUS technique. ^[4]

Subxiphoid approach ^[4]

• 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.

The subxiphoid approach is preferred for patients in cardiac arrest or if ultrasound is unavailable. ^[4]

Parasternal approach ^[4]

• Entry point: 1 cm lateral to the left sternal border at the 5^th or 6^th intercostal space
• Trajectory: Advance the needle over the rib border toward the pericardium.

Apical approach ^[4]

• 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.

Emergency pericardiocentesis may be performed with minimal equipment, however, additional equipment is required for temporary drain placement. ^[4]

Minimum equipment

• Ultrasound machine
• Sterile gown and gloves
• Sterile full-body drape
• Sterile ultrasound probe cover
• Antiseptic solution
• Large (16–18-gauge, 6 inch) spinal needle
• Syringe: minimum 10 mL; consider larger volumes (e.g. 20–60 mL) for large effusions

Agitated saline apparatus

• Air-filled (0.5–1 mL) syringe
• Saline-filled (8–9 mL) syringe
• Three-way stopcock

Temporary pericardial drain equipment

• Guidewire
• Vascular dilator
• Flexible catheter guide
• 6–8 Fr pigtail catheter
• Plastic drainage tube
• Three-way stopcock
• Water seal

• Obtain informed consent.
• Prepare for ultrasound guidance.
  • Select the optimal pericardiocentesis approach based on effusion size and accessibility on ultrasound.
  • POCUS technique: See “Focused cardiac ultrasound.”
• Initiate cardiac monitoring.
• Position the patient supine with the head of the bed at a 30–45° angle.
• Perform skin preparation and maintain a sterile field, e.g., by using a sterile ultrasound probe cover and full-body sterile drape.
• Consider local anesthesia and/or procedural sedation (e.g., with fentanyl, midazolam) in hemodynamically stable patients.
• Assemble agitated saline apparatus.

The following steps are applicable to both children and adults.

Pericardial puncture ^[4]

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 ^[4]

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 ^[4]

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. ^[6][7]
3. If pericardial drain placement is desired, use the Seldinger technique as follows:
   1. Advance the guidewire through the needle into the pericardial sac.
   2. Remove the needle.
   3. Make a small incision at the site of entry.
   4. Use a vascular dilator to dilate the tissue tract.
   5. Remove the dilator and advance the pigtail catheter.
   6. Remove the guidewire.
   7. Secure the catheter with a suture and apply a sterile dressing.
   8. Connect the catheter to a water seal to drain by gravity.

• CXR obtained
• Patient admitted for postprocedural monitoring ^[8]
• 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! ^[9]

• Diagnostic pericardiocentesis: See “Pericardial fluid analysis.”
• Therapeutic pericardiocentesis: Interpret hemodynamic parameters individually for patients with obstructive shock to evaluate treatment efficacy (see “Management of cardiac tamponade” for details).

• Dysrhythmias
• Pericardial decompression syndrome ^[10]
• Pneumothorax ^[4]
• Pneumopericardium ^[4]
• Rare: liver laceration, ventricular and coronary artery injury ^[6]

The risk of complications is greater if a blind technique is used. ^[5][11]

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