Chapter 39 ■ Pericardiocentesis 275

3. Swabs or gauze pads

4. Gloves

5. Local anesthetic

6. 16- to 20-gauge IV cannula over 1- to 2-inch needle

7. Indwelling drainage catheter (optional)

8. Three-way stopcock

9. Short IV extension tubing (optional)

10. 10- to 20-mL syringes

11. Preassembled closed drainage system as for emergency

evacuation of air leaks, thoracostomy tubes described in

Chapter 38 (optional)

12. Connecting tubing and underwater seal for indwelling

drain (optional)

13. Specimen containers for laboratory studies, if procedure is diagnostic

Nonsterile (See also I)

1. Transillumination device (optional, for pneumopericardium)

2. Echocardiogram/sonography imaging device (optional

in urgent situations)

I. Procedure

1. If ultrasound/echocardiographic imaging is available,

and if time permits, imaging can be performed to determine an optimal needle entry site and angle. In addition, the approximate distance required to reach the

pericardial space can be estimated (15). Even after a

sterile field is created, ultrasound imaging can be performed from a nonsterile area of the chest to monitor

the effusion during the procedure. If imaging is done

from a part of the sterile field, the transducer can

be placed in a sterile sheath (or a sterile glove). Care

should be taken to avoid moving a probe with sterile cover back and forth between sterile and nonsterile

areas.

2. Similarly, evaluation with transillumination can be performed in cases of pneumopericardium, if time permits.

3. Cleanse skin over xiphoid, precordium, and epigastric

area with antiseptic. Allow to dry.

4. Arrange sterile drapes, leaving the subxiphoid area

exposed.

5. Administer local anesthesia if the patient is conscious.

For example, 0.25 to 1 mL of subcutaneous 1% lidocaine instilled within 1 to 2 cm of the xiphoid process.

(See also Chapter 6.)

6. Form a closed system by assembling a syringe, threeway stopcock, and extension tubing so that the stopcock

is open to both the syringe and the extension tubing,

but closed to the remaining side-port .

7. Using the IV needle/cannula, enter the skin 0.5 to 1 cm

below the tip of the xiphoid process, in the midline or

slightly (0.5 cm) to the left of the midline. The needle

should be at a 30- to 40-degree angle to the skin, and

the tip should be directed toward the left shoulder

(Fig. 39.4). A different approach may be used in certain

cases, for example, if an echocardiogram suggests that

most of the fluid is right-sided or apical.

8. Advance the needle until air or fluid is obtained.

a. A rhythmic tug, corresponding to the heart rate, may

be felt as the needle enters the pericardium.

b. If ultrasound imaging is available, needle position

can be determined either by visualizing the tip of

the needle within the pericardial space or by demonstrating that the amount of pericardial fluid is

diminishing as fluid is aspirated (Fig. 39.5). Some

authors have described reinfusing a small amount of

the aspirated fluid while imaging to observe the

location of microcavitation echoes (15,20,21).

9. Fix the needle in position and advance the cannula

over the needle into the pericardial space. Remove the

needle, and connect the cannula to the closed system

syringe for aspiration.

10. Aspirate as much fluid/air as possible. If the syringe fills,

use the third port of the stopcock to empty the syringe,

or to attach a second syringe, and then aspirate more,

repeating as needed. If diagnostic studies are desired,

the fluid should be transferred to appropriate specimen

containers.

a. If bloody fluid is aspirated, there could be a serosanguineous or hemorrhagic effusion, or the needle

might have entered the heart (usually the right ventricle). There are a few clues that can be helpful in

determining whether the needle has entered the

heart (see J).

b. Note that small single-lumen catheters may easily

become blocked.