A. Pericardiocentesis is an important and potentially lifesaving procedure whereby a needle is inserted into the space between the visceral and parietal pericardium for the purpose of either sampling or draining pericardial contents (fluid, blood, pus, or gas).

1. Diagnostic pericardiocentesis is performed to obtain small amounts of pericardial fluid for culture, cytologic study, or other fluid analyses.

2. Therapeutic pericardiocentesis is intended to drain fluid from the pericardial space to relieve pressure that limits diastolic filling.

3. Diagnostic and therapeutic pericardiocenteses are best performed electively, under controlled circumstances, with echocardiographic or fluoroscopic support.

4. Management of a patient with severe hemodynamic compromise may require that pericardiocentesis be performed on an emergency basis without imaging support.

C. Pericardial anatomy. Normally, only 15 to 50 mL of clear fluid is present in the pericardial space, its composition similar to that of plasma ultrafiltrate.

1. Visceral pericardium is composed of a single layer of mesothelial cells covering the myocardium and is loosely adherent to the underlying muscle by a network of blood vessels, lymphatics, and connective tissue.

2. Parietal pericardium is composed of a thick layer of fibrous connective tissue surrounding another mesothelial monolayer. This fibrous capsule is relatively nondistensible.

1. Several disease states may lead to inflammation of the pericardium or fluid accumulation including infections (viral, bacterial, fungal, parasitic), malignancies, certain rheumatologic disorders, uremia, myocardial infarction, recent cardiac surgery, and myocardial rupture.

2. The composition of the fluid may become exudative, purulent, or frankly bloody depending on the underlying cause.

E. Cardiac tamponade. Abrupt accumulation of fluid of 250 mL or less may lead to the clinical signs and symptoms of tamponade with equalization of pressures in all four cardiac chambers due to the relative noncompliance of the parietal pericardium. However, with slowly developing effusions, the
parietal pericardium is able to stretch, and significantly larger amounts of fluid (sometimes >2 L) may accumulate without hemodynamic compromise. Three other clinical conditions promote hemodynamic compromise, even in the absence of large pericardial effusion: intravascular volume depletion, impaired ventricular systolic function, and ventricular hypertrophy with decreased elasticity of the myocardium (diastolic dysfunction).

1. In the patient with tamponade physiology, the treatment is drainage of the pericardial fluid. While awaiting performance of pericardiocentesis, some authors recommend medical treatment with volume infusion and, if needed, use of inotropic agents and vasoactive drugs. Medical treatment should be viewed as only a temporizing measure. It should be cautioned that aggressive fluid resuscitation may actually worsen the hemodynamic picture by intensifying the ventricular interactions and likely proves beneficial only to those patients who are hypovolemic. Administration of diuretics is contraindicated. Mechanical ventilation should be avoided if possible as it may further impair cardiac filling and output.

2. If time allows, a coagulation profile should be checked and corrected.

3. The authors recommend performing right heart catheterization whenever possible to measure pressures before and after pericardiocentesis.

4. Traumatic pericardial effusion, myocardial rupture, aortic dissection, and severe bleeding disorders are relative contraindications. No absolute contraindication to pericardiocentesis exists.

1. Site preparation: 2% chlorhexidine gluconate and 70% isopropyl alcohol combination solution or equivalent (10% povidone-iodine solution is used only when there is a sensitivity to the chlorhexidine), large sterile drape, sterile gowns and gloves, masks, and caps; 1% lidocaine (without epinephrine), atropine, and code cart to bedside.

2. Procedure: a pericardiocentesis kit or an 18-gauge, 8-cm thin-walled needle with blunt tip; number 11 blade; multiple syringes (20 to 60 mL); ECG; hemostat; sterile alligator clip; specimen collection tubes; and pericardial drain if indicated.

3. Postprocedure: sterile gauze, dressings, and sutures.

1. The universal protocol should be followed, and maximum barrier precautions should be utilized.

2.

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