38: Pericardiocentesis

I. INDICATIONS

1. Emergency evacuation of air or fluid in the treatment of cardiac tamponade (inability of the heart to expand with decreased stroke volume and cardiac output) caused by pericardial effusion (accumulation of excess fluid) or pneumopericardium (accumulation of air) in the pericardial space. Early recognition and intervention are paramount.

   1. Cardiac tamponade secondary to a pericardial effusion. A rare but life-threatening complication of central venous catheters, including percutaneous central venous catheters (CVP) and umbilical venous catheters (UVC). Etiology is unclear but proposed causes include a direct puncture of a vessel or myocardium by the tip of the catheter during insertion or delayed perforation secondary to erosion of the cardiac or vascular wall. Keep a high index of clinical suspicion in a neonate who has a central line and suddenly has cardiovascular collapse that does not respond to resuscitation or resistance to external cardiac compressions and has no air leak by thoracic transillumination. It is more common with lines in the right atrium, and the median time to occurrence is 3 days after a central venous catheter insertion. A chest radiograph may not be diagnostic; an echocardiogram is but may delay treatment. Mortality is high.

   2. Cardiac tamponade secondary to a pneumopericardium. Rare but is very dangerous and usually occurs with other air leak syndromes, with severe lung pathology, with a history of vigorous resuscitation, and/or a history of assisted ventilation. (See Figure 11–18 for a radiograph of pneumopericardium.)

2. To obtain pericardial fluid for diagnostic studies in infants with a pericardial effusion. Pericardial effusion is rare in neonates and most commonly occurs in a hydropic or septic infant. Other causes include thyroid dysfunction, cardiac and pericardial tumors, congenital anomalies (diaphragmatic hernia/eventration, ruptured ventricular diverticulum), infections, surgically related (postoperative), autoimmune, idiopathic, and other causes.

II. EQUIPMENT

Povidone-iodine solution, sterile gloves, gown, sterile drapes, a safety-engineered 22- or 24-gauge 1-inch catheter-over-needle assembly, extension tubing, 10-mL syringe, 3-way stopcock, lidocaine, and underwater seal if the catheter is to be left indwelling, transillumination device for pneumopericardium, transthoracic echocardiogram/ultrasound device.

III. PROCEDURE

Note: If a central venous catheter is in place and a pericardial effusion is suspected, stop infusion of fluids into the catheter immediately.

1. Ideally, pericardiocentesis is performed with the help of echocardiography/ultrasound. Besides diagnosing the pericardial effusion, it helps guide needle insertion to reduce complications. With a pneumopericardium, thoracic transillumination may be helpful. With sudden cardiovascular collapse, time does not allow these tests, and an immediate aspiration is necessary. Emergency pericardiocentesis should not be delayed, as it is life-saving. In certain cases, a quick betadine prep, followed by a “blind” needle insertion with aspiration, is necessary. If time permits, it is best to follow these steps.

2. Perform an echocardiogram to diagnose and show the pericardial effusion. It will also help to determine the site and angle of entry and allow an estimation of the distance the needle should go in. ...