Pericardiocentesis

Summary of the Procedure:

Pericardiocentesis is used to relieve fluid accumulation in the pericardial space. Pericardial effusion can lead to increased intrapericardial pressure resulting in impairment of cardiac filling (cardiac tamponade). Affected patients can have clinical signs of weakness and collapse. Physical examination can reveal muffled heart sounds, weak peripheral pulses, and distended jugular veins. In addition, the increased intrapericardial pressures lead to decreased cardiac output and ultimately can cause systemic venous congestion resulting in pleural and abdominal fluid accumulation.

Indications To diagnose and remove fluid in the pericardial space.
Limitations Small volumes of fluid can be difficult to retrieve.
Complications Most commonly ventricular tachyarrhythmia or premature beats when catheter contacts myocardium. Less commonly trauma to the myocardium, cardiac vessels, or lungs can occur resulting in hemothorax, pneumothorax.

Tearing of the pericardial space leads to relocation of the effusion into the pleural space and typically does not lead to clinical consequences as the fluid volume released is small in comparison to the size of the pleural cavity.
Contraindications Severe coagulopathy. If leakage of blood from the heart (e.g., left atrial tear) is suspected, cautious removal of fluid is needed.
Supplies/instruments 16-20 gauge over-the-needle IV catheter.

Syringe +/- extension set for easier maneuverability around patient.

Three-way stopcock helpful when removing large volumes of fluid so that syringe doesn’t have to be detached from catheter when voiding sampl and re-aspirating.

ECG for continuous monitoring during and after procedure.

Bolus of 2 mg/kg lidocaine in case of severe ventricular tachycardia during procedure.
Position Sternal or lateral recumbency.
Restraint Typically performed under sedation, can also be performed under anesthesia.

 

Landmarks:

Details of the Procedure:

  1. Position animal in sternal or lateral recumbency. Sedation of animal facilitates positioning.
  2. Clip and aseptically prepare to include your landmark at the 3rd to 5th intercostal space. Prepared site typically extends from 2nd to 6th/7th intercostal space. Drapes can be used.
  3. Infiltrate entry site with lidocaine prior to needle entry. Advance slowly through skin, subcutaneous and muscular tissue, to pleural space. Draw back on syringe at each site before infusing lidocaine.
  4. Attach syringe to end of catheter/stylet.
  5. Insert catheter/stylet through body wall at landmark, perpendicular to skin. Advance through skin, intercostal muscle. A decrease in resistance or a “pop” might be appreciated when the pleural and pericardial space are entered.
  6. A flash of fluid is often identified in the hub of the catheter when the pericardial effusion is entered. Gentle aspiration on the syringe can confirm the effusion has been reached.
  7. Remove stylet and attach collection system; assistant aspirates on syringe while clinician performing pericardiocentesis holds catheter in place.
  8. Observe ECG – signs of arrhythmia during procedure could indicate that the myocardium is being contacted or punctured by the catheter.
  9. If a scratching or vibration on the end of the catheter is detected, gently withdraw the catheter slightly as this could be the heart coming into contact with the catheter tip as fluid is being removed.
  10. Once negative pressure is identified and no fluid can be removed, the catheter is removed from the thoracic cavity.
  11. Save fluid in EDTA and red top tube for cytologic analysis +/- culture (if indicated).

 

We have prepared an 18-G IV catheter, small syringe, and 3-way stopcock with an extension set for this small dog’s pericardiocentesis. Not shown are the 30 cc syringe and larger collection bowl we will use to aspirate fluid once the pericardial space has been entered. The materials are sitting in a sterile part of packaging while the clinical is double checking landmarks.
The patient is sedated and restrained in lateral recumbency, with flow-by oxygen in front of the dog’s nose. We have a pulse oximeter, blood pressure, and ECG monitor on this dog. You can use full draping of the site to help maintain sterility. In this dog, we have elected to use the sterile glove package at the ventral aspect of the dog to provide a sterile barrier as this is where manipulation of the syringe and extension set will take place.

 

Video of Pericardiocentesis:

 

 

 

 

 

 

License

VETM 4540: Medical Procedures Copyright © by Shauna L. Blois; Anthony Abrams-Ogg; and Alice Defarges. All Rights Reserved.

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