Chapter 22

• • Therapeutic: Impending cardiac tamponade.

• Diagnostic.

• • Infectious pericarditis.

• Rule out an oncologic process.

• Compromise in the patient’s hemodynamic status.

### Relative

• • A blood dyscrasia in which a patient may have a significant bleeding complication.

• A cutaneous infection in the area of the most feasible sights for pericardiocentesis.

• A significantly elevated diaphragm, a grossly enlarged liver, or profound ascites, which all change the standard landmarks of inserting the pericardiocentesis needle in the subxiphoid area.

• Under such circumstances, use the intercostal approach.

• • Povidone-iodine or equivalent sterilization substrate to cleanse the subxiphoid area.

• 1% or 2% lidocaine or xylocaine.

• 25-gauge, 1.5-inch-long needle.

• 16- or 18-gauge needle, ≥ 1.5 inch.

• Floppy tip wire that can be introduced through the needle.

• Pigtail catheter with multiple side holes as well as an end hole.

• Scalpel.

• 3-way stopcock.

• 30-mL or 60-mL syringe and suture kit.

• ECG monitor, pulse oximeter, and blood pressure cuff.

• • Infection and bleeding can be minimized with proper technique.

• Pneumothorax (unusual).

• Laceration of the liver (unusual).

• Coronary injury (unusual).

• Cardiac perforation (unusual).

• • Ideally, a patient should be continuously monitored with echocardiography and fluoroscopy in an interventional radiology or cardiac catheterization laboratory.

• Frequently, this is not an option, and bedside pericardiocentesis without portable fluoroscopy is performed. In this circumstance, the patient should be sedated.

• Respiratory and hemodynamic status should be monitored by assistants, so that the physician can concentrate on performing the pericardiocentesis.

• • Prepare and drape the subxiphoid area in the usual sterile fashion.

• If the subxiphoid approach might be difficult (due to an unusually located heart or elevated diaphragm), consider preparing the left sternal border.

• All equipment should be readily available and an assistant should be available to help with manipulation of needles, wires, and catheters.

• • Supine position, with 10–30 degrees of reverse Trendelenburg.

• Occasionally, the partially sitting position may be required or beneficial.

• • Makes an orthopneic patient more comfortable.

• May allow for most of the pericardial fluid to position inferiorly or closer to the drainage site.

• • Prepare the subxiphoid area and left sternal border.

• Administer 1% or 2% lidocaine approximately 0.5–1 cm below the left costoxiphoid angle using a 25- or 27-gauge 1.5-inch-long needle.

• • Infiltration of the lidocaine should be superficial as well as deep, pushing the needle superiorly, posteriorly, and leftward.

• Withdraw fluid each time the needle is passed deeper within the skin and subcutaneous tissues.

• To allow for easier passage of the needle, precut the skin with the scalpel before introducing the 16- or 18-gauge 1.5-inch to 2.5-inch needle.

• Insert the larger needle at an approximate 30–45-degree angle with the abdomen with constant negative pressure on the syringe.

• Monitor ECG very carefully for evidence of dysrhythmias or ST segment changes (evidence ...

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