What is the role of pericardiocentesis in the emergency department (ED) setting?

From the Guidelines

Pericardiocentesis is a life-saving procedure that should be performed immediately in the emergency department setting for patients with cardiac tamponade, using ultrasound guidance and a subxiphoid approach whenever possible. The procedure is indicated for patients presenting with signs of tamponade, including hypotension, elevated jugular venous pressure, and muffled heart sounds (Beck's triad), along with pulsus paradoxus and electrical alternans on ECG 1.

Key Considerations

• The subxiphoid (subcostal) route is the preferred approach, with the patient positioned at 30-45 degrees 1.
• Ultrasound guidance significantly improves safety and success rates and should be used whenever available 1.
• Continuous ECG monitoring is essential during the procedure to minimize the risk of complications such as arrhythmias, coronary artery or cardiac chamber puncture, haemothorax, pneumothorax, pneumopericardium, and hepatic injury 1.
• The procedure provides immediate hemodynamic improvement by relieving pressure on the heart, allowing for proper ventricular filling and restoration of cardiac output.

Procedure Details

• After sterile preparation, a 16-18 gauge needle attached to a 50mL syringe is inserted at a 30-45 degree angle just below the xiphoid process and directed toward the left shoulder 1.
• Once the pericardial space is entered, aspirate fluid slowly and send samples for analysis (cell count, culture, cytology, and biochemistry) 1.
• A pigtail catheter can be left in place for continued drainage if needed, with extended pericardial catheter drainage (up to 30 ml/24 h) potentially reducing recurrence rates 1.

Complications and Limitations

• Pericardiocentesis carries a risk of complications ranging from 4 to 10% depending on the type of monitoring, the skill of the operator, and the setting (emergency vs. urgent vs. elective) 1.
• The procedure may have additional limitations/dangers when pericardial fluid is not free and when located in a lateral or posterior position or < 10 mm, in which case a surgical approach might be safer, depending on local expertise and availability 1.

From the Research

Role of Pericardiocentesis in the ED Setting

• Pericardiocentesis is a life-saving procedure that is performed to aspirate fluid from the pericardial space in patients who have severe pericardial effusion that is causing hemodynamic compromise 2.
• The current gold standard for pericardial fluid aspiration is ultrasound-guided pericardiocentesis, which provides real-time visualization of the needle trajectory and surrounding structures 2.
• Point-of-care ultrasound (POCUS) can effectively identify pericardial effusions and guide appropriate treatment, leading to a decreased time to pericardiocentesis and decreased length of hospital stay 3.

Indications and Outcomes

• Pericardiocentesis is indicated as an emergency procedure in patients with hemodynamic compromise secondary to cardiac tamponade 4.
• The procedure can be performed in various settings, including the emergency department, ambulance, or helicopter emergency medical service 5, 4.
• Predictors of in-hospital mortality and outcomes include hemodynamic instability, non-neoplastic/non-idiopathic etiology, and neoplastic etiology 6.

Techniques and Considerations

• A novel in-plane technique with a lateral-to-medial approach via the right parasternal and a high-frequency probe can be used for ultrasound-guided pericardiocentesis 2.
• The technique provides real-time visualization of the needle and surrounding structures, which may potentially help to avoid complications and improve accuracy 2.
• Close monitoring of patients with known or suspected pericardial injuries is important due to their potential for the development of life-threatening complications 5.