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PERICARDIOCENTESIS

In my experience, pericardiocentesis is easy. The difficult part is to get the mental fortitude to initiate the procedure in a high pressure situation. 

Historically, the typical location for pericardiocentesis was subxyphoid. Since the late 1990, US guided drainage has become the standard of care (1). Now, guidelines recommend the parasternal or apical (at the deepest pocket) location for drainage. Studies have shown that practices have changed over time: the para-apical location is the most popular and the subxyphoid approach is only used 15% of the time (2).

TECHNIQUE

Prepare your equipment prior to the procedure. You may use a long 16g needle or a pericardiocentesis kit. 

AGITATED SALINE

The key to pericardiocentesis is to be sure you are in the pericardial space. Some effusions may be bloody, making it tricky to know whether you have accidentally entered the cardiac chamber. Agitated saline can be used like a contrast agent to confirm needle position before aspiration. Agitated saline is saline with suspended small air bubbles. This is prepared by having two syringes connected by a luer lock with one syringe having a tiny amount of air. Pass the saline from one syringe to the other until the saline is agitated with air. Air, being highly reflective will appear hyperechoic on the echo screen. If you are in a hurry, withdraw some fluid from the saline sachet, add air to the sachet and then push the saline back and forth between the sachet and the syringe. 

from European Heart Journal, Volume 35, Issue 34, 7 September 2014, Pages 2279-2284, https://doi.org/10.1093/eurheartj/ehu217 (3)

Once you find the ideal location (deepest fluid pocket closest to the skin), insert the needle in plane, withdrawing on the plunger at all times. Once the pericardium is breached inject some agitated saline. You will see hyperechoic bubbles enter the pericardial space but not within the cardiac chamber. Once you are certain you are in the pericardium, aspirate the fluid or insert a drainage catheter. 

A4C showing injection of agitated saline

PARASTERNAL

The main risks with the parasternal approach is causing a pneumothorax or bleeding due to internal mammary artery puncture. 

Some articles suggest finding the deepest pocket with the echo probe but then using the linear probe for the procedure in parasternal. This allows better visualisation of superficial structures such as the internal mammary artery (4). 

from Eur J Emerg Med. 2018 Oct; 25(5): 322-327 (4).

Whichever transducer you use, insert the needle in plane 2 cm lateral to the sternal edge and keep to the centre of the intercostal space. This will ensure you avoid the internal mammary artery and the neurovascular bundle.

APICAL

The main risk with this approach is creating a pneumothorax or damaging the intercostal neurovascular bundle. Make sure you pass the needle above the rib below. 

Use the echo transducer for this approach and insert the needle in plane, keeping in mind that the probe marker side on the screen is on the right in echo. 

SUBXYPHOID

This approach is the traditional one and allows you to use the abdominal transducer. Have the transducer marker to the patient's right and angle the needle towards the patient's left shoulder, coming into the skin from the probe marker side. Injected agitated saline will appear anterior to the RA and RV.

Agitated saline appearing in the pericardial space, but not within the heart in the clip on the right

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REFERENCES

1. Ristić AD, Imazio M, Adler Y, Anastasakis A, Badano LP, Brucato A, Caforio AL, Dubourg O, Elliott P, Gimeno J, Helio T, Klingel K, Linhart A, Maisch B, Mayosi B, Mogensen J, Pinto Y, Seggewiss H, Seferović PM, Tavazzi L, Tomkowski W, Charron P. Triage strategy for urgent management of cardiac tamponade: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J. 2014 Sep 7;35(34):2279-84. doi: 10.1093/eurheartj/ehu217. Epub 2014 Jul 7. PMID: 25002749.

2. Tsang TS, Enriquez-Sarano M, Freeman WK, Barnes ME, Sinak LJ, Gersh BJ, et al. Consecutive 1127 therapeutic echocardiographically guided pericardiocentesis: clinical profile, practice patterns, and out- comes spanning 21 years. Mayo Clin Proc. 2002;77:429-36.

3. Arsen D. Ristić, Massimo Imazio, Yehuda Adler, Aristides Anastasakis, Luigi P. Badano, Antonio Brucato, Alida L. P. Caforio, Olivier Dubourg, Perry Elliott, Juan Gimeno, Tiina Helio, Karin Klingel, Aleš Linhart, Bernhard Maisch, Bongani Mayosi, Jens Mogensen, Yigal Pinto, Hubert Seggewiss, Petar M. Seferović, Luigi Tavazzi, Witold Tomkowski, Philippe Charron, Triage strategy for urgent management of cardiac tamponade: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases, European Heart Journal, Volume 35, Issue 34, 7 September 2014, Pages 2279-2284, https://doi.org/10.1093/eurheartj/ehu217

4. Osman A, Wan Chuan T, Ab Rahman J, Via G, Tavazzi G. Ultrasound-guided pericardiocentesis: a novel parasternal approach. Eur J Emerg Med. 2018 Oct;25(5):322-327. doi: 10.1097/MEJ.0000000000000471. PMID: 28509710; PMCID: PMC6133212.