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I. INDICATIONS

  1. Emergency evacuation of air or fluid from the pericardial space in the treatment of cardiac tamponade (inability of the heart to expand with decreased stroke volume and cardiac output) and hemodynamic instability caused by pericardial effusion (accumulation of excess fluid in the pericardial space) or pneumopericardium (accumulation of air in pericardial space). Early recognition and intervention are paramount and can be lifesaving because mortality can be high (up to 67%).

    1. Cardiac tamponade secondary to a pericardial effusion. A rare but life-threatening complication of central venous catheters, including PICC and UVC. Incidence is 1% to 3%. Etiology is unclear, but proposed causes include a direct puncture of a vessel or myocardium (areas of weakness and incomplete muscularization may occur in neonates) by the catheter tip 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 has resistance to external cardiac compressions and has no air leak by thoracic transillumination. Possible signs include hypotension, tachycardia, decreased/diminished heart signs, poor perfusion, decreasing arterial saturation, decreased heart sounds, increased jugular venous pressure (very difficult to assess in an infant), pulseless electrical activity with a central line, and pulsus paradoxus (a drop in systolic blood pressure >10 mm Hg during inspiration seen on blood pressure waveform and on echocardiography). The Beck triad (hypotension, increased jugular venous pressure, and distant heart sounds) is described in cardiac tamponade. Pericardial effusion is more common with lines in the right atrium; the median time to occurrence is 3 days after catheter insertion (range, 0–37 days). A chest radiograph may not be diagnostic; an echocardiogram is, but may delay treatment. Note: Pericardial effusion and cardiac tamponade can occur with a central venous catheter in the correct position. It is felt that total parenteral nutrition (especially intralipid) permeates into the interstitium and into the pericardial sac.

    2. Cardiac tamponade secondary to a pneumopericardium. Rare but very dangerous, and usually occurs with other air leak syndromes, severe lung pathology, a history of vigorous resuscitation, and/or a history of assisted ventilation. Early recognition (see signs above) and intervention are important. A chest radiograph can be diagnostic with lucency around the cardiac border. (See Figure 12–22)

  2. To obtain pericardial fluid for diagnostic studies in cases of 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 (intrapericardial mixed germ cell tumor and intrapericardial teratoma have been reported in infants), congenital anomalies (diaphragmatic hernia/eventration, ruptured ventricular diverticulum), postoperative, and idiopathic.

II. EQUIPMENT

Antiseptic solution (eg, povidone-iodine solution, chlorhexidine); sterile gloves; gown; sterile drapes; a safety-engineered, 22- or 24-gauge, 1-inch catheter-over-needle assembly; 21- or 23-gauge butterfly needles; extension tubing (if catheter to be left indwelling); 10-mL syringe; 3-way stopcock; lidocaine; underwater seal ...

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