What is the management of pericardiocentesis?

From the Guidelines

Pericardiocentesis should be performed under echocardiographic or fluoroscopic guidance by an experienced operator in a monitored setting, with careful monitoring and follow-up care after the procedure to minimize complications and ensure optimal outcomes. The management of pericardiocentesis involves several key steps, including:

• Patient observation in a monitored setting for at least 24 hours post-procedure, with continuous cardiac monitoring to detect any arrhythmias or hemodynamic changes 1
• Vital signs should be checked every 15 minutes for the first hour, then hourly for 4 hours, and then every 4 hours if stable
• The puncture site should be regularly inspected for bleeding or hematoma formation, and a sterile dressing should be maintained for 24-48 hours
• Pain management typically includes acetaminophen 650mg every 6 hours as needed, with opioids such as hydrocodone/acetaminophen 5/325mg every 6 hours reserved for moderate to severe pain
• If a pericardial drain was placed, it should be monitored for output (documenting amount and character every 4 hours), kept secure, and removed when drainage is less than 50ml/24 hours
• An echocardiogram should be performed within 24 hours to assess for reaccumulation of fluid
• Patients should be instructed to report symptoms such as chest pain, shortness of breath, dizziness, or fever
• The underlying cause of the pericardial effusion must be addressed with appropriate therapy, which may include antibiotics for infectious causes, colchicine 0.6mg twice daily for inflammatory conditions, or specific treatments for malignancy or autoimmune disorders 1 Some key considerations in the management of pericardiocentesis include:
• The use of echocardiographic or fluoroscopic guidance to minimize the risk of complications such as arrhythmias, coronary artery or cardiac chamber puncture, haemothorax, pneumothorax, pneumopericardium, and hepatic injury 1
• The importance of careful patient monitoring and follow-up care to detect any potential complications early and ensure optimal outcomes
• The need to address the underlying cause of the pericardial effusion with appropriate therapy to prevent recurrence and improve patient outcomes 1

From the Research

Management of Pericardiocentesis

The management of pericardiocentesis involves several key steps and considerations, including:

• Indications: Pericardiocentesis is primarily indicated for the management of emergent cardiac tamponade 2 and can also be used for diagnostic purposes 3, 4.
• Technique: The procedure typically involves inserting a needle into the left xiphocostal angle perpendicular to the skin and advancing it until it reaches the pericardial fluid 2. Echocardiographic-guided pericardiocentesis is considered the standard of care in contemporary practice 5, 3.
• Catheter management: A catheter can be inserted using the Seldinger technique for fluid drainage 2, and extended pericardial drainage may be considered in select patients 5.
• Monitoring: Patients should be monitored continuously for recurrent tamponade, which may result from catheter blockage or fluid reaccumulation 2.

Complications and Safety

Pericardiocentesis is generally considered a safe procedure when performed by skilled physicians with appropriate imaging guidance 5, 3, 4. However, potential complications can include:

• Major complications: Such as mediastinal hematoma, pleuropericardial shunt, and cardiac chamber puncture 3, 6.
• Minor complications: Such as vasovagal reactions, transient AV block, and acute pulmonary edema 3, 6.
• Risk factors: Patients with coagulopathy and thrombocytopenia may be at increased risk of complications, but echocardiographic-guided pericardiocentesis can still be performed safely in these patients by expert operators 5.