Pericardiocentesis

DOCUMENTATION

EQUIPMENT

  • Spinal Needle
  • 3-way stopcock
  • 20ml syringe
  • Pericardiocentesis kit
  • Chloroprep
  • Sterile Drape
  • Sterile Gloves
  • Sterile Gown
  • Faceshield
  • Ultrasound machine

PROCEDURE

General:

  • Clean the skin (i.e. chlorhexadine)
  • If time permitting, use lidocaine 1-2%
  • If time permits: elevate the chest to 45 degree angle, and decompress abdomen if distended
  • 16-18 gauge needle, 5-8 cm in length is ideal
  • Attach a saline filled syringe and gently aspirate as needle advanced
  • You can inject agitated saline once pericardial space is entered to confirm placement (can also check EKG for ST elevations, than 2 far and need to withdraw)
  • After confirmation, pass a wire through the sheath and use a 6-8 French dilator
  • Pass an introducer over the wire after dilator is removed (6-8 French) (just like central line kit)
  • Remove sheath and wire and leave cordis in place

Subxiphoid view:

  • Provides most comprehensive information for screening view
  • Place probe in transverse plane at left costal margin at point of xyphoid process and aim to left shoulder

Parasternal view:

  • Next most useful view
  • Place transducer in left parasternal area between second and fourth intercostals space

Blind Pericardiocentesis:

Intercostal approach:

  • Best approach, near the cardiac apex is safer
  • Insert the needle perpendicular to the skin in the left 5th intercostals space medial to the border of cardiac dullness (immediately lateral to sternum is preferred)

Subxiphoid approach:

  • Insert the needle between the xiphoid process and the left costal margin at 30-40 degree angle to the skin
  • Aim towards the left shoulder

Apical approach:

  • Less commonly used
  • Insert 1 cm lateral to the intercostals space and below apical beat, within area of cardiac dullness
  • Aim towards the right shoulder

US guided peracardicentesis:

  • Preferred method
  • Ideal skin puncture site is where the largest fluid collection is closest to the skin
  • Anterior chest approach is preferred (reduced risk of liver damage)
  • Also reduced risk for lung puncture (air (lung) obscures fluid so would not see fluid if going through lung)
  • Stay away from internal mammary arteries (3-5 cm from parasternal border) and neurovascular bundles under ribs

Complications: Inadvertent puncture of myocardium, lung, liver, vessels

PROCEDURE NOTE

Date:

Indication: Diagnostic/therapeutic removal of fluid from the pericardial space

Resident:

Attending:

Consent was obtained and a time-out was completed verifying correct patient, procedure, site, and positioning. The patient’s thorax was prepped and draped in sterile fashion. 1% Lidocaine was used to anesthetize the surrounding skin area. Ultrasound was(?)was not used to identify the fluid and observe the needle entering the pericardial space. The needle was introduced into the pericardial space. Appropriate fluid return was obtained and fluid was(?)was not removed for study. The needle was then removed. The patient tolerated the procedure well and there were no complications. Blood loss was minimal.Chest x-ray was performed to assess for pneumothorax.