Pericardiocentesis

Overview

Pericardiocentesis is a medical procedure utilized to drain excess fluid from sac around the heart (pericardium). This procedure is often employed as an immediate intervention for cardiac tamponade, a life-threatening condition that can lead to cardiac arrest.

During pericardiocentesis, a needle is carefully inserted through the chest wall and guided to the pericardium. At this point, physicians can choose to either insert a drainage catheter to gradually remove the accumulated fluid or use the needle itself to directly withdraw the excess fluid.

Reasons for undergoing the procedure

The pericardium is a fluid-filled sac that encases and safeguards the heart, allowing it room to expand and fill with blood in between heartbeats when everything is functioning normally. However, when the pericardium becomes overly filled with fluid, it results in a condition known as pericardial effusion. This condition restricts the space available for the heart to expand during each heartbeat.

In the case of slow-developing effusions, the pericardium has more time to gradually accommodate the excess fluid. Conversely, when effusion occurs rapidly, the accumulating fluid places immediate pressure on the heart, preventing the pericardium from adequately expanding. This leads to reduced blood pumping by the heart, resulting in a medical emergency known as cardiac tamponade.

Cardiac tamponade can be life-threatening because it hinders the heart’s ability to fill its chambers and pump blood properly, potentially leading to cardiac arrest within minutes or hours. It requires immediate medical intervention.

Pericardiocentesis can be performed in non-emergency situations or as a potential emergency treatment, depending on the circumstances. Pericardiocentesis is used to treat cardiac tamponade in emergency situations, as well as significant pericardial effusions that may lead to cardiac tamponade.

You could require pericardiocentesis treatment if you have any of the following common causes of cardiac tamponade and pericardial effusion:

• Heart cancer
• Heart or kidney failure
• Advanced cancer
• Hypothyroidism
• Radiation exposure
• Medication reaction
• Heart attack (most likely if the heart wall ruptures)
• Tuberculosis
• Inflammation or infection of the pericardium. This covers illnesses caused by bacteria and viruses, such as those that arise from COVID-19 or in HIV-positive individuals.
• Immune system disorders such as scleroderma, lupus, and rheumatoid arthritis

Risks

Complications associated with pericardiocentesis can occur in a range of 5% to 40% of cases. The risk of complications is minimized when imaging techniques like echocardiography or fluoroscopy are used to guide the healthcare provider in accurately placing the needle. However, in severe situations, pericardiocentesis can be performed without imaging assistance. Nevertheless, this approach is exceedingly rare and should only be considered as a last resort in critical circumstances.

The process includes putting a needle in close proximity to a number of your important organs and major blood vessels, even with imaging. This implies that any of the following could be hurt:

• Liver.
• Stomach.
• The main blood vessels close to the heart.
• Heart. This may result in bleeding, an arrhythmia, or a heart attack. It may also interfere with your heart’s electrical system. Both conditions have the potential to be serious, even fatal, and the bleeding may require immediate cardiac surgery to stop.
• Lungs. A potentially fatal disease known as lung collapse can result from injuries and punctures.
• Pericardium. This may result in a leak of fluid into your chest or an air bubble in the pericardium.

An infection can also result from any medical procedure that requires skin contact. Your immune system may mount an overpowering defense when these infections spread. Sepsis, the overreaction, is a serious medical emergency that poses a risk to life.

Before the procedure

Once a doctor diagnoses cardiac tamponade or pericardial effusion, they will evaluate the severity of the condition and recommend the most suitable course of action. Administration of a local anesthetic is typically the initial step in this process.

The level of urgency dictates the preparation required. In non-emergency situations, such as slow-growing effusions, the doctor can schedule the procedure. In most cases, a local anesthetic is administered, except in the most critical situations.

Before the procedure, you may consume clear beverages up to two hours prior to the operation, but it’s essential to fast (refrain from eating) for eight hours leading up to the procedure day.

Furthermore, the medical team will undertake the following steps:

• Establish an IV (intravenous) line: This is done to facilitate the direct administration of medications or fluids into a vein in your body.
• Prepare your skin: The healthcare provider will trim any hair in the area where the needle will be inserted. Additionally, they will use an antiseptic to thoroughly cleanse the same area, which is a preventive measure against infections. Often, multiple locations are prepped to save time in case the medical professional needs to swiftly adjust the needle’s angle during the procedure.
• Establish monitoring of vital signs. In order to track your blood pressure, respiration, heart rate, and blood oxygen levels, sensors must be attached. Electrodes, or sensors that pick up the electrical activity in your heart, may also be attached in order to perform an Electrocardiogram (ECG or EKG). Providers may be able to modify needle insertion based on variations in your heart’s electrical activity.
• Give out more oxygen. Supplemental oxygen can also be given to those with low blood oxygen levels or at risk for low blood oxygen levels, using a mask or a tube inserted under the nose.

During the procedure

A process called pericardiocentesis includes multiple medical professionals with various backgrounds. It’s likely to involve a few doctors, nurses, imaging technicians, and other professionals.

Imaging guidance

The doctor doing this surgery will consult with an imaging technician to determine the most straightforward and safest approach to the pericardium before putting in the needle. The most common type of imaging is ultrasonography, sometimes known as an echocardiography, which can be done quickly and safely during the procedure. Because imaging enables the physician to precisely place the needle, it is particularly crucial.

In cases of severe crises, a clinician can perform this surgery without imaging assistance. Nonetheless, there is a greater chance of complications and this is really uncommon. Unless there is no other option, it is typically not an option.

Needle placement

Your doctor will numb the area shortly prior to inserting the needle with a local anesthetic, unless there is an imminent risk of cardiac arrest. In order to make it easier to place the needle, they could also make a little cut on your skin with a scalpel.

There are various locations in the pericardium where the needle can be inserted, depending on where the fluid is. The most typical place is:

• Substernal, which is the area beneath your breastbone, or sternum. The most common method typically provides simple, direct access to your pericardium.

Less frequent points of entrance are:

• Parasternal, or above the breastbone. The front of your chest has something somewhat off-center. By entering via your front ribcage, this method allows medical professionals to reach your heart.
• Apical. This method enters your body from the side, between your ribs. It gets its name from the fact that it targets a portion of the pericardium close to the apex of your heart.

After the needle is inserted, it will be angled to enter your pericardium. The healthcare provider can begin extracting the excess fluid from the pericardium once the needle tip is in place.

Removing enough fluid from your pericardium may just take a few minutes, depending on its volume. In order to drain fluid more gradually, they could place a catheter tube if there is a lot of it.

Your doctor has two options: either remove the catheter or the needle after drawing out enough fluid, or leave the drainage catheter in place for a few days to take out additional fluid. They will bandage the area to complete the procedure after extracting the needle or drain.

After the procedure

After the procedure, your doctor may opt to analyze the fluid extracted from the pericardium. This analysis can help identify the underlying cause of the fluid buildup. To confirm the complete removal of fluid, they will also conduct another echocardiography or ultrasound examination. If a drainage tube is left in place, daily ultrasounds will be performed to ensure the fluid has entirely dissipated before the tube is removed.

Outcome

Many individuals will start to experience an improvement in their condition either during or immediately after the removal of fluid. The duration of your overall recovery can vary based on the severity of your case, its underlying cause (especially if it stemmed from an injury), and any additional medications or treatments administered. Your doctor is the best source of guidance regarding what to expect during your recovery and when you can safely resume your regular activities.