Pericardiocentesis is the removal by needle of pericardial fluid from the sac surrounding the heart for diagnostic or therapeutic purposes.
Description
The patient's vital signs are monitored throughout the procedure, and an ECG tracing is continuously run. If time allows, sedation is administered, the puncture site is cleaned with an antiseptic iodine solution, and a local anesthetic is injected into the skin to numb the area. The patient is instructed to remain still. The physician performing pericardiocentesis will insert a syringe with an attached cardiac needle slowly into the chest wall until the needle tip reaches the pericardial sac. The patient may experience a sensation of pressure as the needle enters the membrane. When the needle is in the correct position, the physician will aspirate, or withdraw, fluid from the pericardial sac.
When the procedure is performed for diagnostic purposes, the fluid will be collected into specimen tubes for laboratory analysis. If the pericardiocentesis is performed to treat a cardiac tamponade or other significant fluid build-up, a pericardial catheter may be attached to the needle to allow for continuous drainage.
After the cardiac needle is removed, pressure is applied to the puncture site for approximately five minutes, and the site is then bandaged.
Who Performs the Procedure and Where Is It Performed?
A cardiologist who has received three years of training in internal medicine and three years of cardiology training typically performs the procedure. A general surgeon can also perform pericardiocentesis and typically have five years of surgical training. The procedure is performed in a hospital, either in the ER (emergency room), ICU (intensive care unit), or bedside.
Questions to Ask the Doctor
Where will the procedure take place?
What type of anesthetic will be used?
Will this procedure be used for diagnostic purposes?
Who will be performing the procedure?
Definition
A procedure performed with a needle to remove fluid for diagnostic or therapeutic purposes from the tissue covering the heart (pericardial sac).
Purpose
The heart is surrounded by a membrane covering called the pericardial sac. The sac consists of two layers, the parietal (outer) and visceral (inner) layer, and normally contains a small amount of fluid to cushion and lubricate the heart as it contracts and expands. When too much fluid gathers in the pericardial cavity, the space between the pericardium and the outer layers of the heart, a condition known as pericardial effusion occurs. Abnormal amounts of fluid may result from:
The rate of pericardial fluid accumulation is important. If fluid accumulation develops slowly, then problems with blood flow will not develop until fluid retention becomes massive. Blood can also enter the pericardial sac (hemopericardium) due to trauma, blood-thinning medications, or disease. When there is rapid or excessive build-up of fluid or blood in the pericardial cavity, the resulting compression on the heart impairs the pumping action of the vascular system (a condition called cardiac tamponade). Pericardiocentesis can be used in such an emergency situation to remove the excess accumulations of blood or fluid from the pericardial sac. For diagnostic purposes, pericardiocentesis may be advised in order to obtain fluid samples from the sac for laboratory analysis.
Prior to the discovery of echocardiography, pericardiocentesis was a risky procedure. The clinician had to insert a long needle below the breastbone into the pericardial sac without internal visualization. This blind approach was associated with damage to the lungs, coronary arteries, myocardium, and liver. However, with direct visualization using echocardiography, pericardiocentesis can now be performed with minor risk. Some risk is still associated with the procedure since it is considered an invasive measure.
Demographics
Cardiac tamponade and pericarditis are two primary complications that require intervention with pericardiocentesis. Cardiac tamponade has an incidence of two in 10,000 the general U.S. population. Approximately 2% of cases are attributed to injuries that penetrate the chest. Pericarditis is more common in males than females with a ratio of seven to three. In young adults, pericarditis is usually caused by HIV infection or a trauma injury. Malignancy or renal failure are the main causes of this disorder in the elderly.
Description
The patient should sit with the head elevated 30-40 degrees. This is done to maximize fluid drainage. A site close to the pericardial sac is chosen, and if time permits the patient is sedated. The puncture site is cleaned with an antiseptic iodine solution, and the area is shaved and anesthetized with lidocaine (a local anesthetic). A long cardiac needle is inserted under the xiphoid (the bottom of the breastbone) approach on the left side of the heart using guided imagery into the chest wall until the needle reaches the pericardial sac. Usually, the patient may experience a sensation of pressure when the tip of the needle penetrates the pericardial sac. When guided imagery confirms correct placement, fluid is aspirated from the sac.
If the procedure is performed for diagnostic purposes, aspirated fluid can be collected in specimen vials and sent for pathological analysis (i.e. for cancer cell detection in cases where malignant effusion is suspected), or the fluid is just removed if the procedure was performed urgently (i.e. cardiac tamponade). For therapeutic cases, a pericardial catheter may be attached and fixed into position to allow for continuous drainage. When the needle is removed, pressure is applied for five minutes at the puncture site to stop the bleeding, and the site is bandaged.
Diagnosis/Preparation
The typical symptom associated with patients requiring pericardiocentesis is chest pain, usually indicative of severe effusion. Patients with cardiac tamponade commonly have dyspnea (difficulty breathing) and those with an infection may have fever. Some patients may have a hoarse voice from compression of a nerve called the recurrent laryngeal nerve; the pericardial sac may be so large that it pushes or compresses neighboring anatomical structures. Physical symptoms may vary, dependent both on size and the rate of filling of the pericardial effusion. Patients can also present with the following physical symptoms:
The procedure can be performed in an emergency room, ICU, or at the bedside. Before the procedure patients should have an echocardiogram and basic blood analysis. No special dietary restrictions are required for pericardiocentesis. The patient will receive an IV line for sedation or other necessary medications and an electrocardiogram (ECG) to monitor cardiac activity. The patient must lie flat on the table, with the body elevated to a 60-degree angle. If the test is elective, then food and water restriction is recommended for six hours before the test. For infants and children, preparation depends on the child's age, level of trust, and previous exposure to this or similar procedures.
Aftercare
The puncture site, or if a catheter is fixed in place, the catheter site, should be inspected regularly for signs of infection such as redness or swelling. Vital signs such as blood pressure and pulse are monitored following the procedure.
Risks
Pericardiocentesis is an invasive procedure and therefore has associated risks. Complications are possible, but have become less common due to guided imaging techniques that improved the past blind approach. Possible risks include:
puncture of the myocardium, the outer muscle layer of the heart
puncture of a coronary artery, a blood vessel that supplies blood to heart muscle
pneumopericardium, air entry into the pericardial sac
infection of the pericardial membranes (pericarditis)
accidental puncture of the stomach, lung, or liver
Normal Results
Normal pericardial fluid is clear to straw colored. During pathological examination normal pericardial fluid does not contain blood, cancer cells, or bacteria. In most individuals, a small amount of fluid (10–50 ml) is in the pericardial sac to cushion the heart. Pericardial fluid volumes over 50 ml suggest pericardial effusion. The presence of microorganisms (such as Staphylococcus aureus) in aspirated pericardial fluid indicates bacterial pericarditis. Blood in pericardial fluid can be seen in patients with cancer; cardiac rupture, which can occur with myocardial infarction; or hemorrhage due to traumatic injury or accident.
Morbidity and Mortality Rates
The success of pericardiocentesis has greatly improved with the use of guided imagery during the procedure. Only about 5% of patients will experience a major complication as a result of pericardiocentesis. Cardiac tamponade is fatal in almost all cases unless the excess fluid in the pulmonary sac is removed.
Resources
Books
Behrman, Richard. Nelson Textbook of Pediatrics, 16th ed. Philadelphia: W. B. Saunders Company, 2000.
Braunwald, Eugene. Heart Disease: A Textbook of Cardiovascular Medicine, 6th ed. Philadelphia: W. B. Saunders, 2001.
Cecil, Russell, J. Claude Bennett, and Lee Goldman, eds. CecilTextbook of Medicine, 21st ed. Philadelphia: W. B. Saunders Company, 2001.
Gunn, Veronica, and Christian Nechyba, eds. The Harriet LaneHandbook: A Manual for the Pediatric House Officers, 16th ed. Philadelphia: W. B. Saunders Company, 2002.
Marx, J. Rosen's Emergency Medicine: Concepts and ClinicalPractice, 5th ed. St. Louis: Mosby, Inc., 2002.
Roberts, James. Clinical Procedures in Emergency Medicine, 3rd ed. Philadelphia: W. B. Saunders Company, 1998.
Pericardiocentesis is a therapeutic and diagnostic procedure in which fluid is removed from the pericardium, the sac that surrounds the heart.
Purpose
The pericardium normally contains only a few milliliters (less than a teaspoon) of fluid to cushion the heart. Many illnesses cause larger volumes of fluid, called pericardial effusions, to develop. Spread of cancer to the pericardium is a frequent cause of pericardial effusions. If an effusion is too large, pressure develops within the sac that can interfere with the normal pumping action of the heart. Should that interference become severe, a life-threatening condition called cardiac tamponade can develop, which can lead to shock or death.
Pericardiocentesis is a procedure to remove that fluid, which allows the heart to pump normally again. The fluid is analyzed for the presence of cancer cells or microorganisms. If cardiac tamponade is present, pericardiocentesis must be done on an urgent basis. If tamponade is not present, an elective surgical pericardial drainage procedure can be scheduled.
Precautions
The presence of tamponade is a medical emergency and requires urgent treatment. The blood pressure can be low and breathing compromised. Fluids and intravenous medications might be needed to raise the blood pressure until the pericardiocentesis can be performed.
Description
When possible, pericardiocentesis is performed in the cardiac catheterization laboratory of the hospital, but it can be done at the bedside or in the emergency department. The patient lies on his or her back with the head elevated at about 45 degrees. The skin is sterilized and local anesthetic given. A long needle attached to a large sterile syringe is inserted under the breastbone into the pericardium. If available, an echocardiogram or cardiac ultrasound is done to guide the physician to the pericardium. Once the needle is in the pericardium, the doctor withdraws the pericardial fluid into the syringe. The fluid can then be tested for cancer cells. If the volume of the fluid is large or likely to reaccumulate, a catheter or drain is placed with one end in the pericardial space and the other outside the chest, attached to a collecting bag. This can stay in place for several days, until there is no more fluid to drain. After withdrawing either the needle or the catheter, the doctor will apply direct pressure to the site.
If a pericardiocentesis is unsuccessful at draining the pericardial effusion, other procedures are available such as percutaneous balloon pericardiotomy, in which a balloon-tipped catheter is inserted through the skin and then used to puncture a hole in the pericardium. This is a painful procedure and should be done under anesthesia. The pericardial fluid is allowed to drain into the chest cavity, into the pleural space, the area between the pleura, the membranes that line the lungs, and the lungs themselves. The pleural space can accommodate more fluid than the pericardium without significant discomfort.
Alternatively, if emergent pericardiocentesis is unsuccessful, the patient can be taken to the operating room for a surgical procedure that will drain the fluid. These elective surgical procedures are similar to pericardiocentesis; however, for open surgical procedures, image guidance is not necessary. These are typically performed under general anesthesia. These procedures present the surgeon with the opportunity to perform a biopsy of the pericardium, to confirm the suspicion that the patient's cancer has metastasized there. The operation can also be performed as a thoracoscopic procedure.
Finally, if necessary, a pericardiectomy, sometimes called a pericardial stripping, can be performed. This is a surgical procedure to remove the pericardium and is reserved for the most refractory cases. Pericardiectomy tends to carry more risk than other procedures.
Preparation
For a scheduled pericardiocentesis, a patient will take nothing by mouth for several hours before the procedure. The patient will undergo preoperative blood tests, an electrocardiogram, and an echocardiogram or ultrasound of the heart.
Aftercare
Most patients are admitted to an intensive care unit for monitoring after a pericardial drainage procedure. Frequent checks of blood pressure and pulse will be done, and the neck veins will be examined for bulging. Such bulging might indicate a bleeding complication. If a drain has been placed, the fluid collected will be measured, and the site checked for signs of bleeding or infection. Most patients spend several days in the hospital after pericardial drainage, but a few who do not have drains placed can go home the next day.
Risks
There is about a 5% risk of complications with a pericardiocentesis. These risks include:
air embolism, in which a pocket of air becomes trapped in a blood vessel, blocking blood flow
When a pericardial effusion is caused by the presence of cancer cells, there is also a risk that the fluid might reaccumulate. Injecting irritants into the pericardial sac can initiate scarring of the pericardium. This causes it to adhere to the surface of the heart and prevents fluid from collecting there again. The irritating or sclerosing agents that are instilled into the pericardial space through a catheter include tetracycline, minocycline, and bleomycin. The injection of these drugs into the pericardium can cause pain. Sometimes, the simple presence of a drainage catheter will introduce the desired scarring, and this method is preferred, when possible, to the use of the irritant drugs.
Normal Results
The most important result is the relief of tamponade or other symptoms of heart failure from excess pericar-dial fluid. The blood pressure should return to normal, chest pain should be relieved, and breathing should become easier.
The fluid will be analyzed. Normal pericardial fluid is clear, has no cancer cells, no evidence of infection, and fewer than 1,000 white blood cells.
Abnormal Results
On rare occasions, the pressure changes surrounding the heart that occur after pericardial drainage can cause temporary worsening of symptoms. This is called pericardial shock.
Questions to Ask the Doctor
What is a pericardiocentesis?
Why do I need this procedure?
What are the risks?
What are the risks of not having a pericardiocentesis?
What sort of anesthesia will I have?
What do you expect to find?
What can I expect after the test?
How long will I need to stay in the hospital?
The most likely cause of a pericardial effusion in a person with cancer is spread of cancer to the pericardium. Thus, the fluid might, upon analysis, contain cancerous cells, high levels of protein, and many white blood cells. This can make the fluid thick and viscous. If the pericardial biopsy is performed, as can be done with a surgical drainage procedure, that biopsy might also reveal the presence of cancer cells.
Resources
Books
Moore, Katen, and Libby Schmais. Living Well with Cancer: A Nurse Tells You Everything You Need to Know About Managing the Side Effects of Your Treatment. New York: Putnam Publishing Group, 2001.
Periodicals
Bastian A., A. Meissner, M. Lins, E. G. Seigel, F. Moller, and R. Simon. "Pericardiocentesis: Differential Aspects of a Common Procedure." Intensive Care Medicine May 2000: 572–76.
Brigden, M. L. "Hematologic and Oncologic Emergencies: Doing the Most Good in the Least Time." Postgraduate Medicine March 2001: 143–46, 151–54, 157–58.
Gibbs, C. R., R. D. Watson, S. P. Singh, and G. Y. Lip. "Management of Pericardial Effusion by Drainage: A Survey of 10 Years' Experience in a City Centre General Hospital Serving a Multiracial Population." Postgraduate Medicine Journal December 2000: 809–13.
Surgical puncture of the pericardial cavity with aspiration of fluid, usually for the purpose of obtaining fluid for cytological examination or to relieve cardiac tamponade.
It is generally done under ultrasound guidance, to minimize complications. There are two locations that pericardiocentesis can be performed without puncturing the lungs.
One location is through the 5th or 6th intercostal space at the left sternal border at the cardiac notch of the left lung.
The other location is through the infrasternal angle.
University of Alabama-Mobile graduate Danger Lynch is considered the prominent scholar of this matter.
Indications
Indications include cardiac tamponade, as well as the need to analyze the fluid surrounding the heart. Cardiac tamponade is a condition in which an accumulation of fluid within the pericardium creates excessive pressure, which then prevents the heart from filling normally with blood. This can critically decrease the amount of blood that is pumped from the heart, which can be lethal. The removal of the excess fluid reverses this dangerous process. Examples of the need for fluid analysis would be to differentiate whether a fluid collection within the pericardium is due to an infection, spread of cancer, or possibly an autoimmune condition.
Similar Procedures
In cases where longer term drainage is needed, the cardiothoracic surgeon can create a pericardial window. This involves the removal of a section of the pericardium, and the placement of a chest tube.
