What are the guidelines for managing a pericardial drain?

Managing a Pericardial Drain

Drain Duration and Removal Timing

The pericardial drain should be left in place for 3-5 days and continued until drainage falls below 25 mL per 24-hour period. 1

• Prolonged drainage is mandatory until the volume obtained by intermittent aspiration (every 4-6 hours) falls to less than 25 mL per day 1
• For malignant or suspected neoplastic effusions, extended pericardial drainage is particularly important due to high recurrence rates of 40-70% 2
• In post-ablation cardiac tamponade, early removal after 30 minutes of no reaccumulation in the electrophysiology laboratory is safe and associated with better outcomes compared to delayed removal in the ward 3

Catheter Maintenance and Patency

Continuous heparinized saline infusion at 3 mL/hour through a flush device maintains catheter patency and prevents blockage. 4

• This technique allows safe drainage for up to 7 days (mean 3.6 days) 4
• The continuous flush prevents catheter obstruction from fibrin or clot formation 4

Monitoring During Drainage

Check drain position in at least two angiographic projections before insertion, and monitor output every 4-6 hours. 1

• Echocardiographic or fluoroscopic guidance should be used during initial placement to minimize complications including myocardial laceration and pneumothorax 1, 5
• Right-heart catheterization can be performed simultaneously to exclude constriction 1
• Drain fluid in less than 1-liter increments to avoid acute right ventricular dilatation 1

Indications for Surgical Intervention

If drainage output remains high (>25 mL/day) at 6-7 days post-pericardiocentesis, surgical pericardial window should be considered. 1

• Pericardial window via left minithoracotomy may be considered for malignant cardiac tamponade with recurrent effusions 2, 5
• Surgical drainage is preferred over prolonged catheter drainage in traumatic hemopericardium and purulent pericarditis 1
• Pericardiectomy should be reserved for pericardial constriction, frequent highly symptomatic recurrences resistant to medical treatment, or complications of previous procedures 2, 5

Special Considerations by Etiology

For malignant effusions, consider intrapericardial instillation of chemotherapeutic agents through the drain before removal. 1, 5

• Cisplatin is most effective for lung cancer pericardial involvement (93% and 83% free of recurrence at 3 and 6 months respectively) 1, 5
• Thiotepa is more effective for breast cancer pericardial metastases 5
• Tetracyclines as sclerosing agents control malignant effusion in 85% of cases 5

Post-Cardiac Surgery Context

In post-cardiac surgery patients, posterior pericardial drainage with a thin 16F drain placed retrocardially significantly reduces posterior effusion and late tamponade. 6

• Continue the thin posterior drain until drainage is less than 50 mL in 24 hours 6
• This approach reduces significant posterior pericardial effusion from 14.3% to 0% and late cardiac tamponade from 5.7% to 0% 6
• Early effective posterior drainage also reduces postoperative atrial fibrillation (10.4% vs 32.7%) 6

Critical Contraindications

Never perform pericardiocentesis in aortic dissection with hemopericardium except for controlled drainage of very small amounts to temporarily maintain blood pressure at 90 mmHg as a bridge to definitive surgery. 1

• Aortic dissection is a major contraindication to standard pericardiocentesis 1
• Relative contraindications include uncorrected coagulopathy, anticoagulant therapy, thrombocytopenia <50,000/mm³, and small posterior or loculated effusions 1