Percadio centesis

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Pericardiocentesis

Definition

Pericardiocentesis is the aspiration of fluid from the pericardial space. The normal pericardial sac contains only 15-50 mL of serous fluid. When fluid accumulates abnormally, a critical point is reached at which intrapericardial pressure negatively affects cardiac filling, causing obstructive shock - a condition called cardiac tamponade. Only removal of fluid can stabilize hemodynamics at that point.

Roberts and Hedges' Clinical Procedures in Emergency Medicine, p. 385

Physiology of Tamponade

The pericardium is semi-elastic. It can tolerate an acute accumulation of 80-120 mL without significant pressure rise (flat portion of the pressure-volume curve). Once a critical volume is exceeded, adding just 20-40 mL can double intrapericardial pressure (steep portion of curve), causing rapid decompensation. Cardiac tamponade typically occurs with an intrapericardial pressure of 15-20 mmHg.

With chronic slow accumulation, the pericardium stretches and can accommodate up to 2,000 mL with minimal hemodynamic effect. Patients may be asymptomatic despite large effusions.

Roberts and Hedges' Clinical Procedures in Emergency Medicine, p. 385-386

Clinical Features of Tamponade

Beck's Triad:

Elevated jugular venous pressure (JVD)
Hypotension
Muffled/distant heart sounds

Additional findings:

Pulsus paradoxus (>10 mmHg drop in systolic BP on inspiration) - a key sign
Tachycardia and restlessness
Kussmaul's sign (paradoxical rise in JVD on inspiration)

ECG findings:

Low voltage in all leads
Electrical alternans (alternating QRS amplitude/morphology as heart swings within fluid)

CXR: "Water-bottle" shaped cardiac silhouette

Echocardiography is the gold standard - shows echo-free space in pericardium and right ventricular/atrial diastolic collapse.

Pfenninger and Fowler's Procedures for Primary Care, p. 1493

Indications

Type	Details
Therapeutic	Cardiac tamponade with shock/hemodynamic instability; cardiac arrest from PEA after other causes excluded
Diagnostic	Determine cause of a pericardial effusion when etiology is unclear

Emergency pericardiocentesis is also indicated during resuscitation from pulseless electrical activity (PEA) when other causes have been excluded.

Tintinalli's Emergency Medicine, p. (Chapter 34)

Contraindications

Absolute: None - if tamponade is causing hypotension, cardiac arrest, or hemodynamic compromise, the procedure is life-saving and must proceed.

Relative:

Coagulopathy
Prosthetic heart valves
Pacemakers/cardiac devices
Traumatic hemopericardium (surgical thoracotomy preferred)
Lack of imaging guidance (ultrasound)
Small, loculated, or posterior effusions
Roberts and Hedges' Clinical Procedures in Emergency Medicine, p. 385

Approaches

Three main needle approaches are used:

Subxiphoid (subcostal) - Most common traditional approach; needle inserted at 45° angle below the xiphoid process, aimed toward the left shoulder. Avoids the pleura and coronary vessels but is furthest from the effusion.
Apical - Most commonly used with echocardiographic guidance; exploits the largest fluid pocket near the cardiac apex.
Parasternal - Needle inserted adjacent to the sternum, avoiding the internal mammary artery (aim for the lateral parasternal position).

Step-by-Step Procedure (Subxiphoid, ECG-Guided)

Position patient semi-recumbent at 30-45° (gravity pools fluid anteriorly and inferiorly)
Monitoring: Attach ECG, pulse oximetry, IV access. Have defibrillator available
Prep and drape the xiphoid and subepigastric region with chlorhexidine
Local anesthesia: Infiltrate skin with 1% lidocaine at the subxiphoid insertion point; anesthetize deeper tissue
Needle insertion: Attach an 18-gauge spinal needle to a 10 mL syringe; connect a V-lead ECG electrode to the needle hub via an alligator clip. Insert just below the xiphoid at a 45° angle, aimed toward the left shoulder, aspirating continuously
Advance 4-5 cm while monitoring the ECG. Stop and withdraw slightly if:
- Increased P-wave amplitude
- ST-segment elevation (current of injury) - indicates epicardial contact
- Ectopic beats
Entry into pericardium: A subtle "pop" or give is often felt; the awake patient may complain of chest pain. Pericardial fluid begins to flow
Seldinger technique: Insert J-tipped guidewire through the needle, remove needle, dilate, and insert a pigtail catheter for continuous drainage
Confirm position: Inject agitated saline - bubbles in the pericardial space (not the ventricle) confirm correct placement
Aspirate: Use 50 mL syringe. Key point: pericardial fluid may be bloody but should not clot (it has been defibrinated). If it clots, the needle is likely in a cardiac chamber - withdraw immediately

Clinical tip: Even removing 20-50 mL of fluid from a tamponade can dramatically improve hemodynamics before complete drainage.

Pfenninger and Fowler's Procedures for Primary Care, pp. 1493-1494

Distinguishing Pericardial Fluid from Blood

Feature	Pericardial fluid	Intracardiac blood
Clotting	Does NOT clot	Clots
Color	Serous, straw, or dark	Bright red
Agitated saline echo	Stays in pericardial space	Fills cardiac chamber

Causes of Pericardial Effusion

By frequency (most to least common):

Malignancy (lung, breast, melanoma, lymphoma, mesothelioma) - most common in adults
Idiopathic (most are presumed viral)
Infectious (viral, bacterial, TB, fungal, HIV)
Post-pericardiotomy syndrome
Connective tissue disease (SLE, scleroderma, RA)
Radiation therapy
Trauma (penetrating - 80-90% of stab wounds; blunt trauma)
Uremia / metabolic disorders
Iatrogenic (central line placement, pacing catheters, CPR)
Drug-induced (hydralazine, phenytoin, anticoagulants, doxorubicin)

Roberts and Hedges' Clinical Procedures in Emergency Medicine, p. 387

Complications

Complication	Notes
Dysrhythmias	Most common; can be life-threatening
Ventricular/atrial puncture or laceration	Most feared; confirmed if fluid clots
Coronary artery injury	Puncture or laceration
Pneumothorax / pneumopericardium	Air entry into spaces
Hemothorax	Vessel injury
Air embolism	Rare
Intra-abdominal injury	Liver injury with subxiphoid approach
Internal mammary artery injury	Parasternal approach risk
Intercostal vessel/nerve injury	Lateral approaches
Fluid reaccumulation	Common if underlying cause not treated
Suppurative pericarditis	Infection

Major complication rate under ultrasound guidance is approximately 1.3-1.6% - much lower than blind technique.

Roberts and Hedges' Clinical Procedures in Emergency Medicine, p. 385; Gluer et al., 2015

Ultrasound Guidance (Current Standard of Care)

Echocardiography-guided pericardiocentesis is now the standard of care in non-emergency settings. It allows:

Identification of the largest and most accessible fluid pocket
Real-time needle visualization
Avoidance of cardiac structures and vessels
Choice of optimal approach (apical is most common echo-guided route)

Fluoroscopy is an alternative when echo is unavailable. Blind technique (without guidance) is reserved for true emergencies when no imaging is available.

Fuster and Hurst's The Heart, 15th Edition; ESC eJournal on Pericardiocentesis

Post-Procedure Care

Leave a pigtail catheter in place if large effusion or risk of reaccumulation
Send fluid for: LDH, protein, glucose, cell count and differential, culture, cytology, ANA, AFB (as clinically indicated)
Monitor for reaccumulation with serial echocardiography
Treat the underlying cause to prevent recurrence

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