Norm of Pericardiocentesis
|Quantity of fluid||10–50 mL|
|Glucose||Approximates blood glucose level|
|Blood streaks||Tuberculosis or tumors|
|Turbid||Infection, pericarditis, or malignancy|
|Grossly bloody||Traumatic tap, cardiac rupture, or bleeding disorders|
|Blood obtained on pericardio-centesis||If blood clots, heart has been entered; if it does not clot, sample is from pericardium|
|Milky||Lymphatic drained into pericardium, chylopericardium|
|Low glucose compared to serum levels||Bacterial infection or malignancy|
|CEA levels||Tumor—correlate with cytology studies|
Usage of Pericardiocentesis
Effusion (pericardial), emergency treatment for pericardial tamponade, and removal of pericardial fluid for diagnostic testing.
Description of Pericardiocentesis
Pericardiocentesis is the aspiration of fluid surrounding the heart and contained within the pericardial sac. The procedure involves the transthoracic insertion of a needle through the intercostal space into the pericardium and may be done with guidance from transesophageal echocardiography, when the effusions are small and harder to locate. Excess fluid may accumulate because of pericarditis, after cardiac surgery, heart transplant rejection, cardiac trauma, myocardial rupture, acute rheumatic fever, metabolic diseases (fluid will likely be clear), or tumor. If the amount is greater than 50 mL or accumulates rapidly, it may result in restricted ventricular filling and stroke volume, which progresses to elevated venous blood pressure, tachycardia, and, eventually, cardiac tamponade. Other less common causes of pericardial effusion are blunt chest trauma in children, sarcoidosis and other connective tissue disorders, and AIDS. Cases of chylopericardium after aortic valve surgery or coronary artery bypass grafting have been recorded.
Professional Considerations of Pericardiocentesis
Consent form IS required unless the procedure is performed as an emergency.
Air embolism, cardiac arrest, cardiac tamponade, coronary artery laceration, dysrhythmias, gastric puncture, hemorrhage, hemothorax, hepatic puncture, hydropneumothorax, infection, laceration of coronary artery, peritoneal puncture, pneumothorax, puncture of cardiac chamber, vasovagal arrest, ventricular fibrillation, and ventricular perforation.
Anticoagulant therapy, bleeding disorders, thrombocytopenia.
- Obtain baseline vital signs and neurologic check, and monitor closely throughout the procedure. The procedure will likely be performed in the cardiac catheterization laboratory or an intensive care unit.
- Have an emergency cart, a defibrillator, and a 12-lead ECG machine at the bedside, with appropriate personnel trained in ACLS.
- Establish intravenous access.
- Obtain 1%–2% lidocaine (Xylocaine), sterile gloves, povidone-iodine solution, and a sterile pericardiocentesis tray. The tray should include a short-beveled, 14- to 18-gauge, 4- to 5-inch cardiac needle or Cath-Over needle (spinal needle); a 25-gauge needle; a 35- to 50-mL syringe; a three-way stopcock; red-topped, green-topped, and lavender-topped tubes; sterile gauze; a Kelly clamp; ground wire; and an alligator clip.
- Perform continuous ECG monitoring before, during, and after the procedure. Observe for development of potentially life-threatening dysrhythmias.
- See Client and Family Teaching.
- Just before beginning the procedure, take a “time out” to verify the correct client, procedure, and site.
- Position the client semirecumbent with the head of the bed elevated between 30 and 60 degrees.
- Cleanse the skin of the chest from the xiphoid process to the left costal margin with povidone-iodine solution.
- The subxiphoid insertion site is injected with 1%–2% lidocaine.
- A sterile alligator clip is used to attach ECG lead V to the aspiration needle, or an echocardiogram is used to guide the needle insertion. In emergency situations, in cardiac arrest, the needle insertion is performed “blind.”
- An open three-way stopcock with a 50-mL syringe attached is connected to the cardiac needle. The needle is then inserted into the subxiphoid area, between the xiphoid process and the costal margin.
- The ECG (grounded) is used to monitor and to guide the needle insertion as follows: The appearance of an acute increase in the QRS complex indicates pericardial penetration. Epicardial ventricular contact by the needle is indicated by elevation of the ST segment and ventricular ectopy, and atrial contact by the needle is indicated by elevation of the PR segment. An abnormally shaped QRS complex may indicate myocardial perforation. Echocardiography is increasingly used, especially in the nonemergency situation to guide pericardiocentesis.
- When the pericardium is penetrated, pericardial fluid should appear in the syringe. Grossly bloody aspirate will occur if a cardiac chamber is perforated. At this point, a Kelly clamp applied to the needle at the point of insertion stabilizes the position. The remainder of the pericardial fluid is aspirated.
- The Kelly clamp and syringe are then removed, and a gauze pad is applied with pressure to the site for 3–5 minutes.
- The pericardial fluid is measured and injected into the red-topped, green-topped, and lavender-topped tubes.
- Label the specimen tubes with the site and time of collection. Write the diagnosis and any recent antibiotic therapy on the laboratory requisition. Send the specimens to the laboratory.
- The client is usually maintained in the intensive care unit to monitor ECG continuously for 24 hours after the procedure.
- Assess vital signs every 15 minutes × 4, then every 30–60 minutes for 2 hours, and then every 4 hours for 24 hours if the client is hemodynamically stable.
- Monitor for symptoms of cardiac tamponade for at least 24 hours. Beck's triad, the classic symptoms of cardiac tamponade, includes neck vein distention, hypotension, and heart sounds that are muffled and distant. The narrowing of pulse pressure (when the systolic and diastolic blood pressure values begin to approach one another) may also be a sign of cardiac tamponade.
Client and Family Teaching
- Inform the client and family about the procedure and the seriousness of the condition. They should, if possible, understand the procedure and the need for ICU care before consent.
- It is important to lie motionless throughout the procedure.
- Ensure that the client and family fully understand the condition related to the pericardiocentesis.
- Signs and symptoms to report to the physician include chest pain, shortness of breath, and dizziness or light-headedness.
- The catheter may be left in place if there is a need for further fluid drainage.
- The family should be approached on CPR readiness and given resources on how to learn CPR.
Factors That Affect Results
- Before pericardiocentesis, echocardiographic localization of the effusion helps to minimize the chance of complications from the procedure.