From the Guidelines
Ultrasound-guided pericardiocentesis is the preferred approach for draining pericardial effusions due to its safety and efficacy. The indications for pericardiocentesis include cardiac tamponade, large pericardial effusions (>20 mm in echocardiography), and smaller effusions for diagnostic purposes 1. The procedure should be performed by experienced operators in a facility equipped for radiographic, echocardiographic, haemodynamic, and ECG monitoring 1.
The steps for the procedure include:
- Positioning the patient in a semi-recumbent position (30-45 degrees)
- Selecting appropriate equipment, including a cardiac ultrasound machine with a phased array probe, pericardiocentesis kit with an 18G needle, guidewire, dilator, pigtail catheter, and sterile drapes
- Identifying the largest accessible fluid collection, typically from the subxiphoid approach
- Preparing the site with antiseptic solution and administering local anesthesia (1% lidocaine)
- Inserting the needle at a 15-30 degree angle to the skin, directed toward the left shoulder, under continuous ultrasound guidance
- Inserting a guidewire through the needle, removing the needle, and placing a pigtail catheter over the wire
- Connecting the catheter to a three-way stopcock and drainage bag, and securing it to the skin
Complications to monitor for include:
- Cardiac puncture
- Arrhythmias
- Pneumothorax
- Infection Ultrasound guidance significantly reduces these risks by providing real-time visualization of cardiac structures and the needle path, allowing for precise needle placement and avoiding vital structures 1.
The use of ultrasound guidance has been shown to decrease the major and minor complications of pericardiocentesis, making it a safer and more effective procedure 1. Additionally, the European Society of Cardiology recommends the use of echocardiography or fluoroscopy to guide pericardiocentesis, as it improves the safety and efficacy of the procedure 1.
In terms of specific patient populations, pericardiocentesis may be particularly useful in patients with malignant pericardial effusions, as it can provide relief from symptoms and improve quality of life 1. However, the procedure should be performed with caution in patients with certain contraindications, such as uncorrected coagulopathy or anticoagulant therapy 1.
Overall, ultrasound-guided pericardiocentesis is a safe and effective procedure for draining pericardial effusions, and its use is recommended by current guidelines and supported by the literature 1.
From the Research
Indications for Pericardiocentesis
- Pericardiocentesis is often indicated for diagnostic and therapeutic purposes, including abnormal accumulation of pericardial fluid with different etiologies 2
- The procedure is performed in an elective or emergent setting, depending on the clinical condition of the patient 2
- Malignancy, predominantly lymphoma, is a common cause of pericardial effusion requiring pericardiocentesis 3
- Dyspnea is a common symptom of presentation with cardiac tamponade, and pericardiocentesis is necessary to relieve the condition 3
Procedure for Pericardiocentesis
- Echocardiography is the primary imaging method for diagnosing, localizing, and quantifying pericardial effusion, as well as evaluating its hemodynamic effects 2
- Ultrasound-guided pericardiocentesis is a safe and effective method, with a high success rate and low complication rate 3, 4, 5
- The in-plane subcostal technique is a novel approach for ultrasound-guided pericardiocentesis, providing full visualization of the needle trajectory throughout the procedure 4, 5
- The use of an indwelling pericardial catheter is key for preventing fluid re-accumulation, and the use of colchicine to prevent fluid recurrence is encouraged whenever possible 2, 6
Settings for Pericardiocentesis
- Pericardiocentesis can be performed at the bedside or in the cardiac catheterization laboratory, depending on the clinical setting and the availability of resources 3
- The bedside setting is the most common setting used for pericardiocentesis, with a high success rate and low complication rate 3
- The emergency department (ED) is also a suitable setting for pericardiocentesis, especially in cases of cardiac tamponade requiring immediate intervention 4