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title: Pericardiocentesis author: "Callum Taylor" output: html_document: css: styles.css tags: notebook: 🌑-FFICM

Pericardiocentesis

What was traditionally a landmark technique has evolved to imaging guided techniques. 1

It's for early management of large symptomatic pericardial effusion and cardiac tamponade. 1

The landmark technique was the blind subxiphoid approach, created in 1911 by Marfan. 1

Tamponade

Life threatening compression of the heart due to increasing pericardial fluid. 1

After expansion of pericardium outwards with increasing fluid, eventually pressure on the cardiac chambers and great vessels occur (when pressure 15-20 mmHg) 1

Right ventricle collapses, and hypotension occurs. 1

Echocardiographic findings of tamponade in effusion may be too sensitive and over diagnose tamponade. 1

You need clinical cardiac tamponade too. That's decompensation from cardiac compression, looking like:

  • Dyspnoea
  • Elevated JVP
  • Hypotension
  • Tachycardia
  • Pulsus Paradoxus 1

3/4 of cases will have at least one of those signs (meaning 1/4 won't have any of those signs!) 1

Indications

Haemodynamically unstable patient, to restore cardiac output. 1

But if more stable can be delayed for up to a few hours. This would be without haemodynamic compromise. Effusions non responsive to medical therapy, or infectious/malignant cause suspected. 1

Mild - Mod Effusions (<20mm) 1 Large Effusions (>20mm) 1

Not indicated in mild-mod effusions as risk of over sensitive diagnosis, self limiting illnesses, and the risk associated with procedure 1

Relative contraindications:

  • Coagulopathy
  • Anticoagulants
  • Thrombocytopaenia (<50) 1

Aortic Dissection/Post Infarction Rupture of Free Wall

These conditions are contraindications but not absolute contraindications. 1

They're contraindications as they risk worsening the dissection or rupturing the myocardium (through improving cardiac output, improving BP, and improved BP ripping worse dissection) 1

But if patient too unstable/surgery not immediately available. Consider it to maintain BP ~90mmHg as bridge to surgery. 1

Approaches

Cardiology/IR/more stable patients could consider:

  • Fluoroscopy in Cath Lab - Generally its role is for if you're already in cath lab for PCI and need to fix iatrogenic rupture
  • CT guided - Generally role is for those with poor US window and loculated effusions 1

Other technique available is:

  • echo guided 1

Echo guided allows you to see position of effusion, ideal entry site, and needle trajectory

You can do echo assisted (identify first then do without), or echo guided (identify then use to follow continuously) 1

Puncture Site

  1. Apical
  2. Subcostal
  3. Parasternal 1

Subcostal is traditional approach as was felt to be safest without imaging. But effusions aren't always equal in all places around heart. 1

The Mayo clinic says the best place to go is where the pericardium is closest to the probe, with largest effusion, with no vital organs between skin and space. 1

The place that's most common for this is para-apical. 1

Apical

Place needle 1-2cm lateral to the apex beat, in 5,6,7th intercostal space. Advance needle over superior border of rib. 1

Disadvantage is the risk of ventricular puncture (left ventricle is close), and risk of pneumothorax. 1

Advantages is left ventricle is thicker than right so more likely to self seal if punctured. Ultrasound means you're likely to avoid lung. 1

Parasternal

Place needle in 5th intercostal space close to sternal margin with needle perpendicular to skin (at level of cardiac notch of left lung) 1

Disadvantage is risk of pneumothorax and damage to internal thoracic vessels 1

Subxiphoid

Place needle between xiphisternum and left costal margin. Once below cartilage lower needle to 15-30 degrees, pointing towards left shoulder. 1

Disadvantage is too steep may pierce peritoneum, too medial may puncture right atrium. 1

Sometimes need to go deliberately through left liver lobe. 1

But is a lower risk of pneumothorax. 1

Equipment

  • Cardiac probe
  • Sterile Cover and sterile gel
  • 16-18g teflon sheathed needle
  • 6fr to 8fr dilator and introducer sheath
  • J tipped guidewire
  • drainage catheter (pigtail angiocatheter - 6-8fr, specifical pericardial drainage set)
  • flushing system for patency of catheter 1

Preparation

  • Know platelets and coag
  • Have PRC available
  • Have ECG monitoring and CVC catheter 1

Steps

  1. Place patient Semi Reclining (30 degrees), rotate to left
  2. Disinfect operative field
  3. Local Anaesthetic at Puncture Site
  4. Probe on best stpot
  5. Needle angle will follow same direction as probe
  6. Attach saline syringe to the 16-18 gauge teflon sheathed needle
  7. Advance needle whilst drawing back until fluid aspirated
  8. Then advance 2mm further
  9. The advance sheath over needle (into the space)
  10. Then remove needle leaving sheath in
  11. To confirm placement you can inject agitated saline into space to see bubbles on echo
  12. Place guidewire through sheath
  13. remove sheath
  14. make incision,
  15. place sheathed dilator (6 to 8 fr dilator) over wire
  16. remove dilator
  17. place in pigtail catheter into sheath
  18. aspirate effusion with syringe and flush with 5ml heparinised saline to fix it 1

You could also have one person do echo one person do procedure 1

You can also get a special needle that clips to probe 1

You would repeat aspiration every four to six hours 1

You'd do CXR after just in case of pneumothorax 1

Sources

  1. Pericardiocentesis in cardiac tamponade: indications and practical aspects. Dr. Caterina Chiara De Carlini. Dr. Stefano Maggiolini. e-Journal of Cardiology Practice. Vol. 15, N° 19 - 11 Oct 2017 ↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩