Why is the patient's pericardial (pericardium) drain still bleeding in the absence of pericardial effusion on echocardiogram (echo)?

From the Guidelines

The continued bleeding from a pericardial drain despite no effusion on echo likely indicates ongoing small-volume bleeding that's being effectively drained before it can accumulate, and I recommend monitoring the drain output volume and characteristics, as well as checking coagulation parameters and reviewing anticoagulation medications. The bleeding could be due to several factors, including irritation of pericardial vessels by the drain itself, incomplete hemostasis at the surgical site, anticoagulation effects, or coagulopathy 1. Some key points to consider in the management of pericardial drains include:

• Monitoring the drain output volume and characteristics, with a decrease in volume and a transition from bloody to serous output being reassuring signs 1
• Checking coagulation parameters to rule out coagulopathy, which can contribute to ongoing bleeding 1
• Reviewing anticoagulation medications, as these can increase the risk of bleeding, and considering their adjustment or discontinuation if necessary 1
• Considering CT angiography if bleeding persists or increases, to rule out any major vascular injury or other cause of bleeding 1
• Keeping the drain in place until output decreases to less than 50-100 mL/day with serous rather than bloody characteristics, as premature removal could allow reaccumulation of fluid and potentially lead to tamponade 1
• If bleeding persists or increases significantly, surgical re-exploration may be necessary to identify and address the bleeding source 1. It's also important to note that the absence of effusion on echo is actually reassuring, as it confirms the drain is functioning properly and preventing fluid accumulation that could lead to tamponade 1.

From the Research

Possible Causes of Bleeding from Pericardial Drain

• The presence of a pericardial drain does not necessarily mean that the bleeding is due to the drain itself, as there could be other underlying causes such as:
  • Ongoing inflammation or infection in the pericardial space 2
  • Residual bleeding from the initial procedure that led to the pericardial effusion 3
  • Anticoagulation therapy, which may increase the risk of bleeding in patients with pericardial effusion 4

Role of Echocardiography in Diagnosing Pericardial Effusion

• Echocardiography is essential in defining the location and size of a pericardial effusion, as well as assessing for signs of tamponade 5, 6
• The absence of a significant effusion on echocardiography does not rule out the possibility of bleeding from the pericardial drain, as the bleeding could be due to other causes

Management of Pericardial Drain Bleeding

• The management of bleeding from a pericardial drain depends on the underlying cause, and may involve:
  • Monitoring and adjustment of anticoagulation therapy 3, 4
  • Administration of protamine sulfate to neutralize heparin in patients with persistent bleeding 3
  • Surgical intervention, such as pericardiectomy, in cases of recurrent or massive bleeding 2