Wilfred Muteweye, MD and Agneta Odera, MD
Tenwek Hospital, Kenya
Essential Operative Steps
- Lines and monitoring (arterial line, CVP, ECG, and saturation monitoring)
- Position patient at 30-45 degrees to facilitate inferior and apical pooling of the effusion
- Localize the pericardial collection using ultrasound guidance (common portals of entry are subxiphoid and apical)
- Administer local anesthetic to skin
- Make a 5mm stab on the identified site with a size 11 blade
- Ultrasound directed access of the collection with an 18-gauge needle while maintaining gentle continuous aspiration
- Confirm needle location by injecting agitated warm saline
- Introduce a J-tipped guidewire into the pericardial fluid pool through the needle
- Dilate the tract
- Insert a size 6-8Fr catheter (pigtail or straight with multiple side holes)
- Connect to a 3 way stop-cock and then to a collecting bag
Potential Complications and Pitfalls
- Injury to the myocardium. To avoid this, ensure continuous real time visualization of the needle and identify the point
where the largest pool is close to the skin. For hemorrhagic collections, injection of agitated warm saline with fireflies
noted in the pericardial space may help confirm the position of the needle. Similarly, iatrogenic intracardiac entry will
yield blood that clots as opposed to hemorrhagic pericardial fluid that does not clot. Contrast injection can also be done
if the procedure is done under CT-fluoroscopic guidance - Injury to the stomach (subxiphoid approach) – ensure that the stomach, if distended, is decompressed using a nasogastric
tube or that the patient has been made NPO for at least 3 hours - Coronary artery injury
- Lung injury with pneumothorax formation
- Liver injury can be particularly morbid if the patient has coagulopathy or elevated INR. In such a case, an apical
approach is preferable if feasible - Internal mammary artery injury (for parasternal approach, the needle should be passed 1cm lateral to the sternum to
avoid the internal mammary artery) - False negative aspiration (rarely, one may have clotted blood in the pericardium)
- Ultrasound may have limitations such as narrow near field visibility. Visibility may also be restricted in patients with
hyper inflated lungs (COPD). Postoperatively, presence of dressings, gas, or mediastinal hematoma may also obscure
needle visibility - Creation of a pericardial-pleural fistula
- Intracardiac local anesthetic injection with risk of fatal arrhythmias
Template Dictation
Preoperative Diagnosis: [INDICATION: Pericardial effusion]
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure Performed: Ultrasound guided pericardial drain insertion
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [SEX] with [DURATION] history of [SYMPTOMS e.g. breathlessness and
chest discomfort]. On examination, the patient had the following signs [BLANK]. Echocardiography revealed [BLANK].
Description of the Procedure: The patient was positioned in the supine position with the head of the bed at 30 degrees. The
skin on the anterior chest wall was prepped and draped in the usual sterile fashion. Using an ultrasound with a sterile probe
cover, the pericardial effusion was identified and the skin adjacent to the most dependent area was marked. 10cc of 1% lidocaine
was used to anesthetize the marked site. A 5mm stab was made with a #11 blade. With an ultrasound probe in the non-dominant
hand, an 18-gauge needle was introduced and directed toward the effusion using the dominant hand. As the needle was being
introduced, continuous gentle aspiration was maintained. Fine adjustments were made to ensure that the tip of the needle was
continuously visible. Upon aspiration of the pericardial collection, the site of the needle was confirmed by real time ultrasound
visualization and by free flow of the effusion on aspiration. The position of the needle was further confirmed by injection of
5mL of agitated saline and noting the presence of bubbles around the myocardium. The guidewire was then threaded into the
pericardial space followed by dilation of the wire tract and insertion of a size 8Fr pigtail catheter over the guidewire. The
guidewire was then withdrawn.
The pigtail catheter position was reconfirmed using the ultrasound. The catheter was then connected to a 3-way stopcock and
then to the collecting drainage bag. Aspiration of as much as was possible of the pericardial collection was done, decanting the
fluid into the collecting bag through the 3-way stopcock. Ultrasound was used to monitor the decrease in the depth of the
collection. The pigtail catheter was sutured to the chest wall. The catheter entry site was then dressed with a sterile dressing.
Instructions to flush the catheter every 4 hours and to monitor drain output was provided.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure
