What is the recommended procedure for performing pericardial centesis?

Pericardiocentesis Procedure

Pericardiocentesis must be performed with either echocardiographic or fluoroscopic guidance by an experienced operator in a facility equipped for radiographic, echocardiographic, hemodynamic, and ECG monitoring under local anesthesia. 1

Critical Pre-Procedure Requirements

• Never perform blind pericardiocentesis except in immediately life-threatening situations where imaging is unavailable 1
• Ensure experienced operator and staff are available 1
• Verify facility has complete monitoring capabilities (radiographic, echocardiographic, hemodynamic, ECG) 1
• Confirm no absolute contraindications exist, particularly aortic dissection 1

Relative Contraindications to Address

• Uncorrected coagulopathy 1
• Active anticoagulant therapy 1
• Thrombocytopenia <50,000/mm³ 1
• Small (<10 mm), posterior, or loculated effusions (consider surgical approach instead) 1

Echocardiography-Guided Technique (Preferred for Bedside)

Echo guidance is technically less demanding, can be performed at bedside, and has high feasibility (93%) with major complication rates of 1.3-1.6%. 1

Entry Site Selection

• Identify the point where effusion is closest to the transducer and fluid collection is maximal 1
• Most commonly: 6th or 7th intercostal space in anterior axillary line 1
• Mark the intended entry point on skin and carefully note the ultrasound beam direction 1

Structures to Avoid

• Liver 1
• Myocardium 1
• Lung 1
• Internal mammary artery (stay 3-5 cm away from parasternal border) 1
• Vascular bundle at inferior margin of each rib 1

Needle Trajectory

• Define trajectory by angulation of handheld transducer 1
• Advance needle while continuously visualizing on ultrasound 1

Fluoroscopy-Guided Technique (Catheterization Laboratory)

Fluoroscopic guidance with hemodynamic monitoring allows simultaneous right-heart catheterization to exclude constriction and provides improved feasibility (93.1% vs 73.3% without imaging). 1

Subxiphoid Approach (Most Common)

• Use Tuohy-17 blunt-tip introducer needle or thin-walled 18-gauge needle with mandrel 1
• Direct needle toward left shoulder at 30-degree angle to skin 1
• This route is extrapleural and avoids coronary, pericardial, and internal mammary arteries 1

Fluoroscopic Technique Details

• Use lateral angiographic view for best visualization of needle position relative to diaphragm and pericardium 1
• Advance needle slowly toward heart shadow and epicardial halo phenomenon 1
• Apply moderate suction while advancing 1
• Inject small amounts of diluted contrast medium intermittently 1

Confirming Needle Position

• If haemorrhagic fluid aspirates freely, inject a few milliliters of contrast under fluoroscopy 1
• Sluggish layering inferiorly confirms correct pericardial position 1

Catheter Placement

• Introduce soft J-tip guidewire through needle 1
• Check guidewire position in at least two angiographic projections before proceeding 1
• Dilate tract 1
• Exchange for multihole pigtail catheter 1
• Evacuate fluid under control of intrapericardial pressure monitoring 1

Fluid Drainage Strategy

• Drain fluid in <1 liter steps to avoid acute right ventricular dilatation 1
• Continue prolonged drainage until intermittent aspiration (every 4-6 hours) yields <25 ml per day 1, 2

Complications and Rates

Overall complication risk ranges from 4-10% depending on monitoring type, operator skill, and clinical setting (emergency vs elective). 1

Major Complications

• Cardiac chamber or coronary artery laceration/perforation (0.9% with fluoroscopy) 1
• Arterial bleeding (1.1%) 1
• Pneumothorax (0.6%) 1
• Haemothorax 1
• Hepatic injury 1

Minor Complications

• Arrhythmias, typically vasovagal bradycardia (0.6% serious arrhythmias) 1
• Vasovagal reactions (0.3% major) 1
• Air embolism 1
• Puncture of peritoneal cavity or abdominal viscera 1
• Infection (0.3%) 1

Rare Complications

• Internal mammary artery fistulas 1
• Acute pulmonary edema 1
• Purulent pericarditis 1

Special Situations Requiring Surgical Approach

• Traumatic haemopericardium 1
• Purulent pericarditis 1, 2, 3
• Loculated effusions in lateral or posterior position 1
• Effusions <10 mm 1

Key Safety Measures

• Direct ECG monitoring from puncturing needle is not an adequate safeguard 1
• Tangential approach using epicardial halo phenomenon in lateral view significantly increases feasibility in small effusions (89.3% vs 76.7% for <200 ml) 1
• Echocardiographic guidance achieves 96% feasibility even in loculated effusions 1