38: Pericardiocentesis

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.

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.

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. Imaging can also help in monitoring the effusion while the procedure is done.

3. If a pneumopericardium is suspected. Thoracic transillumination can be done to help diagnose and also to help monitor the air evacuation while the procedure is done (see Chapter 40).

4. Monitor electrocardiogram and vital signs.

5. 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.

6. Pain management. If time permits, local anesthesia can be administered (0.25–1.0 mL of 1% lidocaine subcutaneously).

7. Prepare the needle assembly. Attach the catheter over needle to a short piece of extension tubing that is attached to a 3-way stopcock. A syringe is attached to the stopcock. Alternative method is to just use a 22- to 24-gauge needle attached to a syringe (no cannula is placed when fluid or air can no longer be aspirated the needle is removed).

8. Identify the site where the needle is to be inserted. Most commonly is ∽0.5 cm to the left of and just below the infant's xiphoid (Figure 38–1).

9. Insert the needle at about a 30-degree angle, aiming toward the midclavicular line on the left. (See Figure 38–1.) Have an assistant apply constant suction on the syringe while advancing the needle.

10. Once air or fluid is obtained (depending on which is to be evacuated). Stop advancing the needle, advance the cannula over the needle, remove the needle from the catheter, and reconnect the cannula to the extension tubing.

11. Withdraw as much air or fluid as possible. The goal is to relieve the symptoms or obtain sufficient fluid for laboratory studies.

12. If an indwelling catheter is to be left in place. Secure it with tape and attach the tubing to continuous suction (10–15 cm H₂O is used).

13. Obtain a chest radiograph or ultrasound. To confirm the position of the catheter and the effectiveness of drainage. Transillumination can also be done.

1. Puncturing the heart. Grossly bloody fluid may indicate that the needle punctured 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 (if ultrasound is not available) is to attach the electrocardiogram (ECG) 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. If cardiac perforation occurs, emergency intervention and cardiac surgeon consultation needed.

2. Pneumothorax or hemothorax. This 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 usually needed.

3. Infection. Strict sterile technique minimizes the risk of infection.

4. Arrhythmias. Usually transient. Repositioning the needle is usually effective, but with persistent arrhythmia, treatment may be necessary.

5. Bleeding. Bleeding is usually superficial and controlled with pressure. Hepatic puncture can occur.

6. Hypotension. May occur if a significant amount of fluid is drained. A fluid bolus may be necessary.

7. Pneumomediastinum. Observation is only required.

8. Pneumopericardium. Treat as above.