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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 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 .
- Diagnostic pericardiocentesis 
- Therapeutic pericardiocentesis 
- Absolute: none
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.
- pericardial space. can be used to confirm needle positioning within the
- ECG leads attached to the needle to help confirm positioning if POCUS is unavailable.
Landmarks and positioning
There are three main approaches to pericardiocentesis. 
Subxiphoid approach 
- 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.
Parasternal approach 
- Entry point: 1 cm lateral to the left sternal border at the 5th or 6th intercostal space
- Trajectory: Advance the needle over the rib border toward the pericardium.
Apical approach 
- 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. 
- 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
- Ready the ultrasound machine.
- Select the optimal ultrasound. based on effusion size and accessibility on
- Initiate cardiac monitoring.
- Position the patient supine with the head of the bed at a 30–45° angle.
- Perform and maintain a , e.g., by using a and full-body sterile drape.
- Consider fentanyl, midazolam) in hemodynamically stable patients. and/or (e.g., with
- Assemble apparatus.
The following steps are applicable to both children and adults.
Pericardial puncture 
- Attach a large (16–18-gauge, 6 inch) spinal needle to a syringe.
- Follow the selected ultrasound guidance. under
- Maintain negative pressure on the syringe and advance until fluid returns.
- Remove the syringe and attach the apparatus.
- Confirm pericardial needle placement by injecting under ultrasound guidance.
- Follow the diagnostic pericardiocentesis steps or therapeutic pericardiocentesis steps as needed.
Diagnostic pericardiocentesis steps 
- Perform steps and confirm proper needle position.
- Aspirate enough fluid for .
- Once fluid is obtained, remove the needle and place an .
Therapeutic pericardiocentesis steps 
Pericardial drain placement is an optional step for patients with a high risk of recurrence.
- Perform steps and confirm proper needle position.
- For cardiac tamponade, aspirate enough fluid to relieve obstructive shock using an appropriately sized syringe. 
- If pericardial drain placement is desired, use the as follows:
- Advance the guidewire through the needle into the pericardial sac.
- Remove the needle.
- Make a small incision at the site of entry.
- Use a to dilate the tissue tract.
- Remove the dilator and advance the .
- Remove the guidewire.
- Secure the catheter with a suture and apply a .
- Connect the catheter to a to drain by gravity.
- CXR obtained
- Patient admitted for postprocedural monitoring 
- Sample sent for pericardial fluid analysis (if desired)
- Procedure documented
- Ultrasound repeated 24 hours postprocedure to assess for recurrent effusion