Pericardiocentesis Needle Direction
When performing pericardiocentesis, the needle should be directed towards the left shoulder at a 30-degree angle to the skin, which aims the needle toward the right atrium. 1
Proper Technique for Pericardiocentesis
Approach and Positioning
- The subxiphoid (or subxiphoid) approach is most commonly used for pericardiocentesis
- A Tuohy-17 or thin-walled 18-gauge blunt-tip introducer needle is used
- The needle is inserted at the left xiphocostal angle, 3-4 mm below the left costal margin
- The needle is directed toward the left shoulder at a 30° angle to the skin 1
Anatomical Considerations
- This trajectory avoids critical structures:
- Coronary arteries
- Pericardial arteries
- Internal mammary arteries (which are 3-5 cm from the parasternal border)
- Vascular bundle at the inferior margin of each rib 1
Procedural Guidance
- Modern pericardiocentesis should be guided by either:
- Fluoroscopy: Provides best visualization of the puncturing needle and its relation to the diaphragm and pericardium
- Echocardiography: Technically less demanding and can be performed at bedside 1
- Blind procedures should be avoided except in immediately life-threatening situations 1
During the Procedure
- The operator applies moderate suction while advancing the needle
- Small amounts of diluted contrast medium may be injected to confirm position
- When pericardial fluid is aspirated, a soft J-tip guidewire is introduced
- After dilatation, a multihole pigtail catheter is inserted for drainage 1
Potential Complications
The complication rate ranges from 4-10% depending on monitoring type, operator skill, and setting urgency 1:
- Myocardial laceration or perforation
- Coronary vessel puncture
- Arrhythmias (commonly vasovagal bradycardia)
- Pneumothorax or hemothorax
- Pneumopericardium
- Hepatic injury
- Air embolism
- Puncture of peritoneal cavity or abdominal viscera 1
Important Considerations
- The needle direction toward the left shoulder at a 30° angle effectively aims toward the right atrium, which is the safest approach to access the pericardial space
- The lateral angiographic view during fluoroscopy provides optimal visualization
- Echocardiography should identify the shortest route where the pericardium can be entered intercostally 1
- The procedure should be performed by experienced operators in a facility equipped for radiographic, echocardiographic, hemodynamic, and ECG monitoring 1
By following this technique with proper imaging guidance, the risk of complications can be minimized while effectively accessing the pericardial space for diagnostic or therapeutic purposes.