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  1. Indications

      1. Treatment of cardiac tamponade caused by pneumopericardium or pericardial effusion. (Note: Pericardial effusions are a rare but life-threatening complication of central venous catheters including umbilical venous catheters. Keep a high index of clinical suspicion in a neonate who has a central line and suddenly has cardiovascular collapse.

      1. To obtain pericardial fluid for diagnostic studies in infants with pericardial effusion.

  2. Equipment. Equipment includes povidone-iodine solution, sterile gloves and gown, a 22-or 24-gauge 1-in catheter-over-needle assembly, sterile drapes, a 10-mL syringe, a connecting tube, and an underwater seal for use if the catheter is to be left indwelling.

  3. Procedure

      1. Ideally, pericardiocentesis is done with the help of echocardiography. This guides needle insertion to decrease the incidence of complications. With pneumopericardium, thoracic transillumination may be helpful. With sudden cardiovascular collapse, time does not allow these tests, and immediate aspiration is necessary. (See Figure 10–17 for a radiograph of pneumopericardium.)

      1. Monitor electrocardiogram and vital signs. Prep the area (xiphoid and precordium) with antiseptic solution. Put on the sterile gloves and gown and drape the area, leaving the xiphoid and a 2-cm circular area around it exposed.

      1. Local anesthesia can be administered (0.5–1% lidocaine subcutaneously). See Chapter 69 for dose.

      1. Prepare the needle by attaching the syringe to it. If you want to leave an indwelling catheter in, a three-way stopcock and tubing should be attached to the needle in addition to the syringe.

      1. Identify the area where the needle is to be inserted. The area most commonly used is ~0.5 cm to the left of and just below the infant's xiphoid (Figure 34–1).

      1. Insert the needle at about a 30-degree angle, aiming toward the midclavicular line on the left (see Figure 34–1). Apply constant suction on the syringe while advancing the needle.

      1. Once air or fluid is obtained (depending on which is to be evacuated), remove the needle from the catheter. Withdraw the necessary amount of air or fluid, that is, enough to relieve symptoms or to obtain sufficient fluid for laboratory studies.

      1. If an indwelling catheter is to be left in place, secure it with tape and attach the tubing to continuous suction.

      1. Obtain a chest radiograph to confirm the position of the catheter and the effectiveness of drainage.

  4. Complications

      1. Puncturing the heart. Perforation of the right ventricle can be avoided by advancing the needle only far enough to obtain fluid or air. Ultrasound guidance is recommended if time permits. Another technique to avoid puncturing the heart is to attach the electrocardiogram anterior chest lead to the needle with an alligator clip. If changes are seen on the ECG (eg, ectopic beats, changes in the ST segment, increase in the QRS voltage), the needle has contacted the myocardium and should be withdrawn. Avoid leaving a metal needle indwelling for continuous drainage. Most needle perforations heal spontaneously.

      1. Pneumothorax or hemothorax can occur if landmarks are not used and "blind" punctures are done. If this complication has occurred, a chest tube on the affected side is ...

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