eMedicine Specialties > Cardiology > Invasive Diagnostic, Interventional, and Surgical Procedures

Pericardiocentesis: Treatment & Medication

Author: Ali A Sovari, MD, Research Fellow, Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles (UCLA)
Coauthor(s): Ravi H Dave, MD, Associate Professor of Medicine, University of California at Los Angeles David Geffen School of Medicine; Abraham G Kocheril, MD, FACC, FACP, Professor of Medicine, Director of Clinical Electrophysiology, University of Illinois at Chicago
Contributor Information and Disclosures

Updated: Jan 28, 2009

Treatment

Medical Care

Aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), steroid, and colchicine are used to treat the inflammation associated with pericardial effusion. The treatment of choice for primary symptomatic moderate-to-large amount of pericardial effusion is pericardiocentesis. A surgical approach is not only preferable but is the treatment of choice for recurrent or chronic pericardial effusions.

• Indications for pericardiocentesis can be summarized as follows:
• Pericardiocentesis is indicated in patients with pericardial tamponade and in those with large recurrent pericardial effusion.
• Symptomatic pericardial effusion is an indication for pericardiocentesis.
• Pericardial fluid drainage is indicated in patients with suspicion of purulent pericarditis.⁹
• Pericardiocentesis can be used for diagnostic purposes, ie, effusion of unclear etiology.
• It can be used to obtain a biopsy specimen of pericardium.
• Pericardiocentesis is indicated for large pericardial effusions that compress other organs (eg, trachea, lung).
• Conservative treatment is as follows:
• Many pericardial effusions can be managed conservatively if there is no evidence of hemodynamic compromise or need for diagnosis based on pericardial fluid. Ultimately, the patient may require removal of the fluid for definitive treatment.
• The patient can be treated medically, which includes support of blood pressure with vascular volume expansion.
• Inotropic agents have no significant role in the management of hypotension due to effusion. Treatment of the underlying cause is important.
• An idiopathic large pericardial effusion occasionally occurs, usually without tamponade. Pericardiocentesis may not be part of the initial management if the effusion does not have any hemodynamic and clinical consequence. Colchicine may be effective for treating these patients; however, sometimes, removal of the fluid is required for definitive treatment.
• Preparation is as follows:
• Elective or urgent pericardiocentesis should be performed by a specialist or other experienced individuals; otherwise, the surgical approach should be pursued.
• Obtain an echocardiogram before the pericardiocentesis procedure to prove the presence of the effusion and to confirm that the effusion is at least of moderate size and is not loculated. Perform this procedure in a place equipped with monitors and 2-dimensional echocardiography or fluoroscopy. Although fluoroscopic guidance has been used more commonly, echocardiographic guidance is becoming more popular, partially because with echocardiography the shortest route to the pericardial sac can be easily identified. Echocardiographic-guided pericardiocentesis can be performed at the bedside, and no exposure to x-ray occurs using this technique.
• A needle aspiration should not be performed on patients with small, organized, or loculated effusions.
• Pericardiocentesis is indicated for large pericardial effusions when symptoms and/or signs of hemodynamic compromise are present (ie, pericardial tamponade). The presence of a significant pericardial effusion should be confirmed by echocardiography and hemodynamic status ascertained by assessment of vital signs and related findings. Hematologic abnormalities that might increase the risk of bedside pericardiocentesis (aPTT, PT, platelet count) are also sought prior to pericardiocentesis.
• If time permits, any clotting abnormality should be corrected. Fresh frozen plasma should be administered if the effusion occurs from thrombolytics, and pericardiocentesis should not be performed unless the tamponade is life threatening. Administration of heparin should be discontinued if the condition is caused by anticoagulation. Pericardiocentesis should be delayed until the clotting profile is normal or protamine is administered, unless the patient is unstable.
• An electrocardiogram should be obtained before the procedure, and electrocardiographic monitoring should be continued during the procedure. If the needle touches the myocardium, the current of injury causes ST-segment elevation on the electrocardiographic monitor.
• Pericardiocentesis tray and other equipment should include the following:
• An 18- to 20-gauge cardiac needle or long central venous catheter with needle introducer
• A 3-way stopcock
• Syringes (10, 20, and 60 mL)
• Antiseptic chlorhexidine and alcohol or povidone-iodine solution
• ECG monitor
• Specimen collection tubes for fluid analysis and cultures; fluid receptacle (1-L vacuum bottle)
• Manometer (for pericardial pressure measurement)
• Small-gauge needle for local anesthesia and 1-2% lidocaine
• Sterile gloves, mask, gown, dressing materials (sterile transparent plastic drape, eg, 1030 Drape,Baxter), and gauze (4 X 4 in)
• Surgical blade (#11)
• Multiple 16- to 18-gauge (5.1-8.3 ctn) polytef sheathed venous Intracath needles (Deseret)
• Sterile isotonic sodium chloride solution (for flushing catheter)
• Emergency medications (eg, atropine, lidocaine, epinephrine)
• Sedating medications
• Frequent vital signs sheet
• Defibrillator with monitor
• The pericardiocentesis procedure is as follows:
• Ensure that the patient is sitting at 30-45° head elevation, which increases pooling of fluid toward the inferior and anterior surface, thus maximizing fluid drainage.
• Select a site that is closest to the pericardial space, avoiding vital structures, such as the internal mammary artery, lungs, myocardium, liver, and vascular bundle at the inferior margin of each rib.
• Shave the skin carefully to avoid any trauma. Anesthetize the local site with lidocaine (1-2%). Make a small incision (approximately 5 mm) to decrease the resistance during needle insertion. Separate the subcutaneous tissue with mosquito grasping forceps.
• Connect the needle with a 3-way stopcock. Ensure that the syringe with 1% lidocaine is connected to the 3-way stopcock on the opposite side of the needle connection. Connect the transducer on the side of the 3-way stopcock. Attach a sterile ECG recorder to the metal part of the needle.
• Insert the needle through the subxiphoid approach on the left side under fluoroscopy. Advance the needle and syringe until the needle tip is posterior to the rib cage. The needle should be advanced toward the shoulder at an angle 15-20° from the abdominal wall. While advancing the needle toward the pericardial space, aspirate the syringe and inject lidocaine for a better analgesic effect. Continue to advance the needle until fluid is aspirated in the syringe or the ECG monitor shows ST elevation.
• Withdraw the needle slowly with negative pressure on the syringe if the ECG shows ST elevation after clearing the needle with lidocaine. Reinsert the needle in a different direction very slowly until fluid is aspirated in the syringe.
• If hemorrhagic fluid is aspirated, a few milliliters of contrast medium are injected, which can be observed surrounding the cardiac silhouette, indicating that the needle tip is in the pericardial space. If the contrast material immediately disappears, then the needle is in one of the cardiac chambers.
• The position of the needle is confirmed by injecting agitated saline through the needle, termed saline echocontrast medium, for confirmation of position. This procedure is particularly important when bloody fluid has been aspirated or when confirming the needle position. If contrast appears in the pericardial space, the procedure can be continued.
• When the needle tip is inside the pericardial space, a soft floppy-tip guidewire is passed through the needle. Wrap this guidewire around the heart. Remove the needle, and insert a soft catheter with multiple side holes over this wire. Remove the guidewire. Connect the catheter hub with the transducer and syringe with a 3-way stopcock. Place the dressing, and secure the catheter to prevent displacement. Ensure that the catheter is flushed with 1-2 mL of fluid to prevent blockage.
• Two different types of catheters are used commonly, the pigtail catheter and the straight catheter. A pigtail catheter is curved and has a soft tip. A straight catheter has side holes, which help to increase drainage and reduce the chances of blockage. The type of catheter selected depends on the surgeon's preference. A more flexible catheter that allows continuous drainage may be preferable.
• The pericardial catheter can be left in the space for 24 hours with continuous closed drainage occurring, using gravity to increase drainage. The catheter should be removed after 24 hours, if possible, because it increases the chances of infection in the pericardial space. However, keeping the catheter in the pericardial space often is necessary to maintain drainage for longer periods. Negative suction should not be used to maximize the drainage.
• Echocardiographic-guided procedure follows the same principles as the fluoroscopy guided. When echocardiography is used as the guide, the operator has more choices regarding the approach to the effusion. One of the most commonly used approaches is the apical approach with inserting the needle along the long axis and toward the aortic valve. In the echocardiographic-guided procedure no contrast media is injected to the pericardium and instead the presence of the needle in the pericardial space can be confirmed by using air bubbles.
• CT-guided pericardiocentesis is a new approach that is indicated specifically for patients in whom ultrasound-guided or radiograph-guided pericardiocentesis is unsuccessful. For example, echocardiographic-guided procedure may have some technical difficulties in obese patients.
• It is recommended to perform the pericardiocentesis (even the echocardiographic-guided procedure) in a cardiac catheterization laboratory where appropriate equipment is available for hemodynamic monitoring and interventions, except under the most urgent conditions.
• Pericardiocentesis with intrapericardial sclerotherapy also is effective in treating patients with malignant pericardial effusion.

Surgical Care

A surgical approach is not only preferable but is the treatment of choice for recurrent or chronic pericardial effusions. Several surgical options are available including subxiphoid pericardial window (SPW), thoracotomy with a pleuropericardial window, and pericardiectomy.

Postcardiothoracic surgery, pericardial effusions may occur early (within 24 h of surgery) or late (within weeks of surgery). Often, postsurgical effusions are located posteriorly and may consist of coagulated blood. For these reasons, detection and percutaneous aspiration can be difficult. This diagnosis should be suspected in postcardiothoracic surgical patients with otherwise unexplained hemodynamic compromise. Surgical drainage is often required in this circumstance.

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