What is the management for clots in a pericardial drain?

Management of Clots in Pericardial Drain

For clots in a pericardial drain, maintain drain patency without breaking the sterile field through continuous irrigation with heparinized saline solution (3 ml/hr) via a continuous flush device to prevent complications from retained blood. 1

Assessment and Initial Management

• Evaluate for signs of tamponade or hemodynamic compromise that may result from drain obstruction (dyspnea, tachycardia, jugular venous distension, pulsus paradoxus, hypotension) 2
• Perform echocardiography to assess for pericardial effusion accumulation and features of tamponade (RV diastolic collapse, RA late diastolic collapse, IVC plethora) 2
• Do not attempt to manually "milk" or "strip" the tubes as this can cause iatrogenic infection, hemorrhage, or disruption of bypass grafts due to high negative pressure 3
• Breaking the sterile field to aspirate or mechanically clear obstructions is not recommended (Class IIIA recommendation) 3

Recommended Approach for Clot Management

• Implement slow infusion of heparinized saline solution (3 ml/hr) via a continuous flush device to maintain catheter patency 1
• This technique has been shown to maintain catheter patency for up to seven days (mean 3.6 days) in patients with pericardial effusions secondary to various causes 1
• Maintenance of chest tube patency without breaking the sterile field is recommended to prevent retained blood complications (Class I recommendation) 3

Drainage Management

• Continue pericardial drainage until the volume of effusion obtained by intermittent pericardial aspiration falls to <25 ml per day 4
• For mediastinal drains after cardiac surgery, they can be safely removed once drainage becomes macroscopically serous 5
• If drainage remains high (>50 mL/day) after 6-7 days, consider surgical pericardial window 6
• For persistent clotting issues despite proper management, consider catheter replacement or alternative drainage approaches 1

Special Considerations Based on Etiology

Post-cardiac Surgery

• Clots are more common following valve surgery than coronary artery bypass grafting alone 4
• Early anticoagulation with warfarin in patients with postoperative pericardial effusion increases risk of clot formation 4
• Consider posterior pericardial drainage which has been associated with significant reductions in tamponade (90% reduction) 3

Malignant Pericardial Effusion

• Malignant effusions have higher risk of clot formation and drain occlusion 6
• If clots persist despite management, consider surgical pericardial window which has lower recurrence rates compared to percutaneous pericardiocentesis 6
• For recurrent malignant effusions with clotting, intrapericardial instillation of sclerosing agents may be considered after clearing the drain 4, 7

Traumatic Hemopericardium

• Clots are common in traumatic hemopericardium and may require surgical drainage rather than catheter management 4
• Urgent surgical treatment is lifesaving in cases of hemopericardium with tamponade 4
• If immediate surgery is not available, pericardiocentesis with intrapericardial fibrin-glue instillation could be an alternative in subacute tamponade 4

Prevention of Drain Occlusion

• Use silicone-rubber drains instead of PVC drains when possible, as they are associated with lower rates of clot formation 3
• Consider the choice of drain location (anterior versus posterior) as posterior pericardial drainage has been associated with reduced rates of tamponade 3
• Implement continuous monitoring of drainage output to detect early signs of drain occlusion 3

Pitfalls to Avoid

• Do not delay intervention when signs of tamponade develop due to drain occlusion, as this is life-threatening 2, 8
• Avoid stripping or breaking the sterile field of chest tubes to remove clots 3
• Do not remove drains prematurely when clots are present, as this may lead to reaccumulation and tamponade 4
• Be vigilant for signs of infection which may complicate management of clotted drains 1