Emergent Pericardiocentesis - A Contemporary Review

Case:

You are the senior resident working an afternoon trauma/critical care shift when a rapid response is called in the hospital. Shortly thereafter, an elderly woman with a history of metastatic colon cancer is brought to you by the nursing staff after losing consciousness while undergoing radiation therapy.

Triage vitals are as follows:

BP 60/40 mm Hg, HR 110/min (irregularly irregular), RR 22/min, SAT 98% on O2 2L NC

You immediately place two large-bore IVs, begin a liter bolus of normal saline, and perform your primary survey.

The patient’s airway is intact, breath sounds are equal bilaterally, heart sounds are distant, and femoral and radial pulses are weak bilaterally. The patient’s extremities are cold. The patient appears anxious but is alert. Your exam is consistent with shock.

You quickly perform a bedside ultrasound. The subcostal long-axis view shows:

Image courtesy of Rithvik Balakrishnan, MD

Interpretation: large pericardial effusion with diastolic collapse of the right ventricle; rapid atrial fibrillation

These ultrasound findings are consistent with echocardiographic cardiac tamponade. Because of apparent hemodynamic instability, an emergent pericardiocentesis is indicated.

1. What are the contraindications of pericardiocentesis?¹

While pericardiocentesis is the definitive treatment for cardiac tamponade, aortic dissection and post-myocardial infarction free wall rupture are contraindications. Surgical drainage is the mainstay of therapy for these two clinical scenarios, however, if surgical intervention is not immediately available or if the patient is peri-arrest, controlled drainage can be performed: small amounts of blood may be aspirated to provide temporary stabilization (maintaining SBP 90 mm Hg^1,2). Ideally in this scenario, a single lumen central line catheter or pigtail catheter would be placed with a three-way stopcock attached to facilitate as needed drainage for temporary stabilization.

Relative contraindications are:

– Uncorrected coagulopathy*

– Anticoagulant therapy*

– Severe thrombocytopenia (platelets under 50,000/mm³)

– Small, posterior, and loculated effusions

– Skin infection at access site

*If situation permits, consider correction with FFP, factor VIIa, or Vitamin K + PCC prior to procedure.

2. What are the potential complications of pericardiocentesis?¹

– Cardiac arrest

– Ventricular puncture

– Coronary artery/vein laceration

– Internal mammary artery laceration

– Pneumothorax

– Liver laceration

– Worsening cardiac tamponade from iatrogenic injury

– Tension pneumopericardium^3,4

– Arrhythmias

3. What is the equipment needed for a pericardiocentesis?^1,12

Pericardiocentesis using sterile technique and real-time ultrasound guidance is the recommended approach for this procedure. Echocardiography-guided pericardiocentesis is the technique of choice because it has the highest rate of success and lowest rate of major complications when compared to the traditional ECG-guided and the blind approach⁴.

You will need the following:

– Ultrasound machine with phased-array (cardiac) and linear (vascular) probes

– Sterile ultrasound probe cover

– One of the following: pericardiocentesis kit, single-lumen central line kit, or a pigtail thoracostomy kit; and a 6F or 8F dilator if a catheter is being left in place

– 18-gauge needle with sheath (preferred) or 18-gauge spinal needle

– Syringe partially filled with saline

– Three-way stopcock

– Cardiac monitor

– Pulse oximetry

– Specimen collection tubes (for cytology and additional studies)

– Sterile gloves and gown

– Chlorhexidine antiseptic prep

– Sterile normal saline for flushing catheter

– Code cart with defibrillator

Please note that using large volume syringes (such as a 60cc syringe) should be avoided as they require excess force to draw fluid, and this may increase the risk of iatrogenic injury during the procedure.

4. What are the anatomic considerations for this procedure?¹

There are three approaches for pericardiocentesis: parasternal, apical, and subxiphoid.

In general, the subxiphoid approach should be reserved only for cardiac arrest as needle passage under ultrasound guidance using this approach can be difficult to visualize, and because the apical and parasternal approaches may minimize the distance the needle must travel to access the pericardial space safely⁶.

Parasternal approach:

Potential organ injury includes the coronary arteries and internal mammary arteries, as well as the myocardium.

The sternal border is flanked by the internal mammary arteries bilaterally. Normally, these arteries lie 3-5mm lateral to the sternal border. Visualization of the vessels with the vascular probe is required for planning the needle approach. The thoracic cavity should be punctured 1 to 2 cm lateral to the parasternal border to avoid these vessels, but not more than 2 cm or 3 cm as this increases the risk of pneumothorax¹¹.

Image of dynamic needle-guided pericardiocentesis using parasternal approach, courtesy of ThePocusAtlas – http://www.thepocusatlas.com/pericardium

Image title: Pericardiocentesis
Submitted to ThePocusAtlas by Ahad Al Saud, Emergency Medicine Physician, @Ahad_AlSaud

Apical approach:

Potential organ injury includes the intercostal arteries, lung parenchyma, and myocardium. If there is aerated lung present during surveillance echocardiography, the apical approach should be avoided as the risk of injury to the lung will be high. Air-filled lung creates a scatter artifact preventing the ultrasound beam from passing; avoidance of the lung is ensured if the pericardium and myocardium are clearly viewed. If no scatter artifact is present, this approach is a viable option⁶.

Apical five-chamber video of cardiac tamponade and rapid atrial fibrillation
Video courtesy of Rithvik Balakrishnan, MD

Subxiphoid approach:

Potential organ injury from this approach includes the liver, stomach, and myocardium. This approach should be avoided if the patient is coagulopathic as the risk of penetrating the liver is high while entering the pericardial space. An advantage of this approach is the lower risks of pneumothorax and injury to the intercostal and internal mammary arteries¹¹.

Subxiphoid image of pericardial effusion – Tahir Ahmad, MD

5. How do I use ultrasound to guide my procedure?⁸

Use the phased-array (cardiac) probe to look for the thickest amount of effusion, paying close attention to the depth of the pericardium (shortest depth preferably), angle, and surrounding structures. Again, the lung is identified by the presence of air artifact and contraindicates needle insertion due to risk of lung injury and obsruction of needle visualization⁸.

When depth and angle are identified, mark the site of needle insertion on the patient. Use an in-plane approach with the needle entering the chest alongside the probe marker (linear/vascular if parasternal approach, phased array/cardiac if apical approach) into the plane of the ultrasound probe to visualize the needle tip.

Injury to the coronary arteries and myocardium is a lethal complication, and as such, the angle of insertion must be duplicated precisely to avoid injury⁸.

6. What are the peri-procedural medical considerations during paracentesis for cardiac tamponade?¹

Airway/Breathing –

Place the patient on pulse oximetry and administer supplemental oxygen as needed. Avoid positive pressure ventilation unless absolutely necessary as this can decrease cardiac output.

Circulation –

The patient should be placed on a cardiac monitor.

In the hemodynamically compromised patient (including but not limited to tachycardia and hypotension as in the presented case), concomitant stabilization measures are necessary. IV fluid is paramount before and during pericardiocentesis. It is not recommended to routinely administer IV fluids in the stable patient as this may compromise cardiac output.

Diuresis and vasoactive agents that increase afterload should be avoided.

Inotropes such as dobutamine may be helpful, but their usefulness is limited because of enhanced endogenous adrenergic surge due to tamponade.

7. How is the procedure performed?^9,10

Prior to the start of the pericardiocentesis, the patient should be placed on cardiac ECG monitoring, pulse oximetry, and blood pressure monitoring. A code cart with ACLS medications and a defibrillator with pads should be at the bedside. In addition, the patient should have adequate large bore IV access. The following procedure guide is written with the assumption that a large-bore needle with sheath attached to a three-way stopcock is available. Alternatives have been previously described.

Parasternal and Apical Approaches:

1. The patient should be placed supine if possible, however, the patient’s head of the bed can be elevated at an angle if it facilitates easier access to the most superficial location of the effusion or increases the patient’s comfort.

2. Identify the safest site of needle insertion with bedside ultrasound, making note of the depth from skin surface to effusion and angle of needle insertion. The ideal site should be at the largest and most superficial pocket of fluid⁷.

3. Avoid areas with aerated lung.

4. If performing a parasternal approach, use the liner/vascular ultrasound probe to identify the internal mammary artery⁸. You will be utilizing the linear/vascular ultrasound probe for pericardiocentesis.

5. Mark the site of insertion. If the best approach is parasternal, this should be at least 1 cm lateral to the sternum to avoid the internal mammary artery but not more than 2 cm or 3 cm laterally as this increases the risk of pneumothorax.

6. Sterilize the area of interest and cover with drape.

7. Anesthetize the area of interest with 1% lidocaine.

8. Using aseptic technique under ultrasound guidance, advance the sheathed-needle (attached to a syringe with saline) through the skin at the angle of insertion, along the superior aspect of the rib to avoid the neurovascular bundle.

9. If utilizing a parasternal, a linear-probe (vascular probe) should be utilized to visualize the area of the cardiac notch–the sternum, internal mammary artery, lung sliding, pericardial effusion, and the myocardium. The needle should enter in a medial to lateral approach at a 45-degree angle to avoid the internal mammary artery and pleural lining, within the plane of the ultrasound probe to visualize the needle tip throughout the procedure⁵.

10. If utilizing an apical approach, the phased-array (cardiac) probe should be utilized, and the needle should enter alongside the probe marker in the plane of the ultrasound probe at the precise angle of entry determined initially during sonographic surveillance, and again, visualizing the needle tip throughout the procedure⁸.

11. Advance the needle while aspirating gently–aggressive aspiration may lead to tissue becoming suctioned into the needle, and this may prevent aspiration of pericardial fluid.

12. When fluid is aspirated into the syringe, further advance the needle slightly (2 mm) and then glide the sheath into the pericardial space while withdrawing the needle. If there is concern about proper needle placement at this time, inject agitated saline (referred to as contrast) to verify placement of the needle into the pericardium. The visualization of contrast in the pericardial space with ultrasound will confirm correct placement, while intraventricular contrast will confirm ventricular placement.

13. Again, confirm the placement of the sheath by attaching a syringe with agitated saline to the three-way stopcock and injecting a small amount into the pericardial space while simultaneously visualizing with ultrasound.

14. Remove as much fluid as possible by gently aspirating. In cases of possible myocardial rupture or aortic dissection, only a small amount of fluid should be removed, enough to obtain hemodynamic stability (i.e. maintain a blood pressure of 90 mm Hg)¹.

15. If a pigtail catheter is to be placed, follow the usual Seldinger technique. Place the J-tipped guidewire by advancing it posteriorly around the heart. Make a small skin incision, dilate with a 6F or 8F dilator, and then advance the catheter over the wire.

16. Confirm placement again with ultrasound and agitated saline.

17. Post-procedurally, perform a repeat lung ultrasound may be performed to rule out pneumothorax. Obtain a chest x-ray to evaluate for pneumopericardium and pneumothorax immediately afterward⁴.

Subxiphoid Approach:

This approach is recommended in the cardiac arrest situation or when ultrasound guidance is not possible. Review the parasternal and apical approach above; similar steps apply unless otherwise indicated.

1. The patient should be positioned head up at a 30-45 degree angle to allow for the myocardium to fall posteriorly within the pericardial sac. The supine position is an acceptable alternative ⁷.

2. Introduce the needle 1cm inferior to the left xiphocostal angle at a 15-30 degree angle to the skin. Direct the needle posteriorly until the tip passes posterior to the bony cage. Direct the hub of the needle towards the diaphragm and advance at a 15-30-degree posterior tilt towards the patient’s left shoulder. Exceeding an angle of 45 degrees can cause laceration of the liver and stomach⁶.

3. Once fluid is aspirated, further advance the needle slightly (2 mm) and then advance the sheath while withdrawing the needle. If no fluid is aspirated, withdraw the needle completely and enter with a more posterior trajectory.

4. If the position of the needle or the sheath is questionable or there is bloody aspirate, inject a small amount of agitated saline and attempt to confirm with ultrasound as described above if available.

5. When proper placement of the sheath is confirmed, follow steps 14 – 17 above.

Conclusion

After drainage of pericardial fluid in the ED, adequate perfusion is restored, and the patient’s mentation is improved. The patient is then immediately taken to the OR for a pericardial window by thoracic surgery.

Pericardiocentesis is a life-saving procedure that all emergency physicians must be competent and comfortable with performing. It is important to be familiar with all possible approaches especially those using ultrasound guidance. Although the subxiphoid approach is the traditional one, multiple studies have shown that the parasternal and apical approaches are safe under ultrasound guidance¹¹. In 2002, Tsang et a. established the safety of using ultrasound-guided pericardiocentesis irrespective of location with a low rate of complications; 21% were subxiphoid approaches, and the apical approach was the most commonly used^8,12. The ideal approach is one that considers the largest and most superficial presence of effusion and avoids vital organs. The safety of the parasternal and apical approaches under ultrasound guidance should make these approaches first-line in the performance of emergency pericardiocentesis.

References

1. Abraham, E., Fink, M. P., Kochanek, P., Moore, F. A., & Vincent, J. L. (2017). Chapter E9 – Pericardiocentesis. Textbook of critical care(7th ed., pp e81-e85). Philadelphia, PA: Elsevier.

2. Cruz, I., Stuart, B., Caldeira, D., Morgado, G., Gomes, A. C., Almeida, A. R., … Pereira, H. (2014). Controlled pericardiocentesis in patients with cardiac tamponade complicating aortic dissection: Experience of a centre without cardiothoracic surgery. European Heart Journal: Acute Cardiovascular Care, 4(2), 124–128. doi: 10.1177/2048872614549737

3. Stawicki, S., Kumar, R., Sinha, A., Lin, M., Uchino, R., Butryn, T., … Shirani, J. (2015). Complications of pericardiocentesis: A clinical synopsis. International Journal of Critical Illness and Injury Science, 5(3), 206. doi: 10.4103/2229-5151.165007

4. Lee, J., Kang, B. S., Kim, C., & Choi, H. J. (2016). Tension Pneumopericardium after Pericardiocentesis. Journal of Korean Medical Science, 31(3), 470. doi: 10.3346/jkms.2016.31.3.470

5. Osman, A., Chuan, T. W., Rahman, J. A., Via, G., & Tavazzi, G. (2018). Ultrasound-guided pericardiocentesis. European Journal of Emergency Medicine, 25(5), 322–327. doi: 10.1097/mej.0000000000000471

6. Custalow, C. B., Roberts, J. R., Thomsen, T. W., Mallemat, H. A., & Tewelde, S. Z. (2019). Chapter 16 – Pericardiocentesis. In Roberts and Hedges clinical procedures in emergency medicine and acute care(pp. 309–331). Philadelphia, PA: Elsevier.

7. Fowler, G. C., & Leferve, N. (n.d.). Chapter 214 – Emergency Department, Hospitalist, and Office Ultrasound (POCUS). In Pfenninger and Fowler’s Procedures for Primary Care(4th ed., pp. 1408–1438). Elsevier.

8. Parrillo, J. E., Puri, N., & Mayo, P. (n.d.). Chapter 18 – Bedside Ultrasonography in the Critically Ill Patient. In Critical Care Medicine: Principles of Diagnosis and Management in the Adult (5th ed., pp. 226–238.e3). Elsevier.

9. Kern, M. J., & Sorajja, P. (n.d.). Chapter 17 – Pericardiocentesis. In The Interventional Cardiac Catheterization Handbook(4th ed., pp. 438–447). Elsevier.

10. Brown, D. L., & Sovari, A. S. (n.d.). Chapter 44 – Pericardiocentesis. In Cardiac Intensive Care(3rd ed., pp. 361–464.e1). Elsevier.

11. Tsang, T. S., Freeman, W. K., Sinak, L. J., & Seward, J. B. (1998). Echocardiographically guided pericardiocentesis: evolution and state-of-the-art technique. Mayo Clinic Proceedings, 73(7), 647–652. doi: 10.4065/73.7.647

12. Tsang, T. S., Enriquez-Sarano, M., Freeman, W. K., Barnes, M. E., Sinak, L. J., Gersh, B. J., Seward, J. B. (2002). Consecutive 1127 Therapeutic Echocardiographically Guided Pericardiocenteses: Clinical Profile, Practice Patterns, and Outcomes Spanning 21 Years. Mayo Clinic Proceedings, 77(5), 429–436. doi: 10.4065/77.5.429