Atlas of Procedures in Neonatology, 4th Edition

Tube Replacement

37

Pericardiocentesis

Alan Benheim

  1. Definitions
  2. Pericardium
  3. A double layer of mesothelial lining surrounding the heart, consisting of the visceral pericardium on the epicardial surface and the parietal pericardium as an outer layer
  4. Between the two layers there is normally a small amount of pericardial fluid (typically <5 mL for a neonate) that is thought to reduce friction.
  5. Pneumopericardium
  6. Collection of air in the pericardial space
  7. Pericardial effusion
  8. Accumulation of excess fluid in the pericardial space
  9. Pericardiocentesis
  10. A procedure to remove air or excess fluid from the pericardial space, usually through a needle, small cannula, or drainage catheter
  11. Pericardial drain
  12. A catheter or other drainage device left in place to allow intermittent or continuous evacuation of air or fluid from the pericardial space
  13. Placed in select situations with recurring accumulation of air or fluid in the pericardial space
  14. Tamponade
  15. Clinical condition with limited cardiac output because of external restriction of expansion of the heart, preventing normal cardiac filling, resulting in a decreased stroke volume and impaired cardiac output
  16. May be caused by:
  17. Fluid or air in the pericardial space
  18. Abnormalities of the pericardium (restrictive or constrictive)
  19. Increased intrathoracic pressure associated with obstructive airway lung disease or tension pneumothorax
  20. Pulsus paradoxus (Fig. 37.1)
  21. Respiratory variation in blood pressure, with a decrease in systolic blood pressure during inspiration during spontaneous respiration. (During positive-pressure ventilation, this is reversed, with a rise in systolic pressure during inspiration.)
  22. This finding occurs during tamponade.
  23. Purpose
  24. To evacuate air to relieve cardiac tamponade
  25. To evacuate fluid to relieve cardiac tamponade
  26. To obtain fluid for diagnostic studies
  27. Background
  28. The heart lies within a closed space, covered by the pericardium, which consists of an inner visceral layer and an outer parietal layer. The pericardial space is between these two layers. Ordinarily, the pericardial space of a neonate has <5 mL of pericardial fluid. This fluid acts as a lubricant to allow the heart to move with minimal friction. If the pericardial space fills with excess fluid, or if air accumulates, then the heart itself has less space available, and the pressure within the pericardium increases. This restricts venous return and impairs cardiac filling. This decrease in venous return and cardiac filling results in a reduced cardiac output. This clinical situation is called cardiac tamponade (1, 2, 3, 4 and 5).
  29. Neonates are at risk for cardiac tamponade
  30. Accumulation of air dissecting into the pericardium from the respiratory system (Fig. 37.2) (4, 5, 6 and 7)
  31. Pericardial fluid accumulation due to perforation or transudate from umbilical or percutaneous central venous catheter (Fig. 37.3) (1, 8, 9, 10, 11 and 12)
  32. Cannulation for extracorporeal membrane oxygenation (13, 14)
  33. Cardiac catheterization, either diagnostic or therapeutic (15)
  34. Postoperative pericardial hemorrhage following cardiac surgery (2, 16)
  35. Postpericardiotomy syndrome, typically 1 to 3 weeks after cardiac surgery (2, 16, 17)
  36. Pericardial effusion as part of generalized edema/hydrops (3, 16)
  37. Pericardial effusions due to infectious or autoimmune causes are less common in neonates than in older children.
  38. Clinical signs of cardiac tamponade may evolve gradually or rapidly (1, 3, 18).

P.286

  1. The primary therapy for cardiac tamponade is to evacuate the pericardial space; volume and pressors may be of transient benefit, but do not usually result in sustained clinical improvement (1, 8, 12, 16, 19).
  2. Cardiac tamponade may require urgent treatment with pericardiocentesis in infants with severe hemodynamic compromise (1, 16, 17).
 

FIG. 37.1. Pulsus paradoxus.

  1. Indications (1, 12, 15, 16 and 17)
  2. Cardiac tamponade due to pneumopericardium
  3. Cardiac tamponade due to pericardial fluid
  4. Aspiration of pericardial fluid for diagnostic studies
 

FIG. 37.2. Chest radiograph with pneumopericardium.

  1. Contraindications
  2. There are no absolute contraindications to performing pericardiocentesis in the setting of cardiac tamponade.
  3. Relative contraindication for diagnostic pericardiocentesis
  4. Coagulopathy
  5. Active infection. (However, infection may also be an indication for diagnostic pericardiocentesis in some clinical situations.)
  6. Limitations
  7. Cannot readily evacuate thrombus
  8. Cannot remove mass lesions
 

FIG. 37.3. Echocardiogram image of preterm infant with pericardial effusion and central venous line in left atrium.

P.287

 

  1. Equipment
  2. Antiseptic solution
  3. Sterile field with aperture drape or multiple drapes to be arranged around access site
  4. Sterile swabs or gauze pads
  5. Sterile gloves
  6. Local anesthetic, as needed
  7. 16- to 20-gauge intravenous cannula over 1- to 2-in needle
  8. Indwelling drainage catheter (optional)
  9. Three-way stopcock
  10. Short intravenous extension tubing (optional)
  11. 10- to 20-mL syringes
  12. Preassembled closed drainage system as for Emergency Evacuation of Air Leaks, Thoracostomy Tubes (optional)
  13. Connecting tubing and underwater seal for indwelling drain (optional)
  14. Transillumination device (optional, for pneumopericardium)
  15. Echocardiogram/sonography imaging device (optional in urgent situations)
  16. Specimen containers for laboratory studies, if procedure is diagnostic
  17. Precautions
  18. Draining a large volume from the pericardial space can alter cardiac preloading conditions significantly, and some infants may require a supplemental intravascular fluid bolus after the pericardium is drained.
  19. Techniques
  20. If ultrasound/echocardiographic imaging is available, and if time permits, then imaging can be performed to determine an optimal 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 even a sterile glove), if needed. Care should be taken to avoid moving a probe with sterile cover back and forth between sterile and nonsterile areas.
  21. Similarly, evaluation with transillumination can be performed in cases of pneumopericardium, if time permits.
  22. Cleanse skin over xiphoid, precordium, and epigastric area with antiseptic. Allow to dry.
  23. Arrange sterile drapes, leaving the subxiphoid area exposed.
  24. Local anesthesia should be administered for the conscious patient. A typical example is 0.25 to 1.0 mL of subcutaneous 1% lidocaine instilled within 1 to 2 cm of the xiphoid process.
  25. Assemble the needle/cannula, three-way stopcock, and syringe so that the stopcock is open to both the needle and the syringe, but closed to the remaining port.
  26. The usual entry point in an infant is 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 elevated 30 to 40 degrees at the skin, and the tip should be directed toward the left shoulder (Fig. 37.4). 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.
  27. While advancing the needle, apply gentle negative pressure with the syringe. Continue advancing until air or fluid is obtained. 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.
  28. 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; seeJ.
 

FIG. 37.4. Insertion of needle/cannula attached to three-way stopcock, in the subxiphoid space, directed toward the left shoulder.

  1. P.288
 

FIG. 37.5. Echocardiogram images of pericardiocentesis. A: Echocardiogram image of pericardial effusion. B: Tip of needle in pericardial space. C: Pericardial effusion partially drained.

  1. A rhythmic tug, corresponding to the heart rate, may be felt as the needle enters the pericardium. Although this tugging sensation can reflect entering the myocardium, it can also be felt while the tip of the needle is positioned correctly within the pericardial space, and it does not necessarily mean that the needle has entered the heart.
  2. 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. 37.5). Some authors have described reinfusing a small amount of the aspirated fluid while imaging, to observe the location of microcavitation echoes (15, 20, 21).
  3. Once the needle is in the pericardial space, as much pericardial fluid or air should be evacuated as possible. To accomplish this, fix the needle in position and advance the cannula over the needle into the pericardial space. Remove the needle, and connect the cannula to a closed system for aspiration, such as a three-way stopcock and a syringe. Aspirate as much fluid/air as possible.
  4. Note that small single-lumen catheters may easily become blocked.
  5. A decision will need to be made whether to leave the cannula in place for any length of time or to remove it once the pericardium has been drained. This decision will vary in individual cases, but factors to consider include the likelihood of reaccumulation and need for repeat drainage versus the risk of infection or entry of free air with an indwelling cannula.
  6. In certain cases, the operator may elect to evacuate the pericardial space directly through the needle, rather than placing a cannula.

P.289

 

  1. Special Circumstances
  2. If ultrasound imaging is available, it may be helpful in planning the needle entry site and angle, as well as anticipating the distance required to reach the pericardial space (2, 15, 17, 20, 21).
  3. If transillumination is positive for free air before the procedure, it can be used to assess the adequacy of air evacuation after the procedure, and to look for evidence of reaccumulation. Because pneumothorax and pneumomediastinum are potential complications, the availability of transillumination may also be helpful after the procedure. Transillumination is not reliable to rule out free air or to distinguish between pericardial air and mediastinal air (5, 6).
  4. Upon initial aspiration of the pericardium, one may encounter several different things: air, serous fluid, serosanguineous or grossly bloody fluid, or fluid resembling infusate from a central line, including parenteral nutrients and lipid solutions. One should not be startled by any of these. Bloody fluid raises the concern that the needle may have entered the heart. Several clues may be helpful in distinguishing between pericardial fluid and intracardiac blood.
  5. In an infant with tamponade, aspirating 10 mL of blood from the heart will have minimal effect on the acute hemodynamics, whereas draining as little as 5 to 15 mL from the pericardial space can result in significant hemodynamic improvement within 30 seconds.
  6. If ultrasound is being used, the pericardial fluid volume will appear to be decreased if the needle is correctly positioned. In some cases, one can reliably identify the needle in the pericardial space (Fig. 37.5) (15).
  7. Placing a few drops on a clean gauze may help distinguish the two sources, because serosanguineous fluid will separate into a central dark red zone and a more serous peripheral zone, but this can take several minutes.
  8. Alternatively, a spun hematocrit can be performed rapidly if the unit has a readily available centrifuge; this also takes a few minutes.
  9. Draining a large volume from the pericardial space can alter cardiac preloading conditions significantly, and some infants may benefit from intravascular fluid boluses after the pericardium is drained.
  10. Pericardiocentesis is often an urgent or emergency procedure. The technique for pericardiocentesis described above applies when there is time for each step. In an infant with significant hemodynamic compromise, the operator may be forced to omit certain steps in the interest of time. This requires a judgment as to the baby's clinical status and the time delay involved for any given step, such as waiting for the ultrasound machine, preparing a larger sterile field, or assembling a three-way stopcock system. In extreme cases, this life-saving procedure might consist of pouring or swabbing Betadine over the subxiphoid area, followed by “blind” aspiration using any available needle and syringe, without anesthetic, and before any other equipment is available at the bedside (15).
  11. Complications (15, 16 and 17,20,21)
  12. Pneumopericardium
  13. Pneumomediastinum
  14. Pneumothorax
  15. Cardiac perforation
  16. Arrhythmia
  17. Hypotension (if a large effusion is drained)

References

  1. Nowlen TT, Rosenthal GL, Johnson GL, et al. Pericardial effusion and tamponade in infants with central catheters. Pediatrics. 2002;110:137.
  2. Tsang TS, Barnes ME, Hayes SN, et al. Clinical and echocardiographic characteristics of significant pericardial effusions following cardiothoracic surgery and outcomes of echo-guided pericardiocentesis for management: Mayo clinic experience. 1979–1998. Chest. 1999;116:322.
  3. Tamburro RF, Ring JC, Womback K.Detection of pulsus paradoxus associated with large pericardial effusions in pediatric patients by analysis of the pulse-oximetry waveform. Pediatrics. 2002;109:673.
  4. Heckmann M, Lindner W, Pohlandt F.Tension pneumopericardium in a preterm infant without mechanical ventilation: a rare cause of cardiac arrest. Acta Paediatr. 1998;87:346.
  5. Hook B, Hack M, Morrison S, et al. Pneumopericardium in very low birthweight infants. J Perinatol. 1995;15(1):27.
  6. Cabatu EE, Brown EG.Thoracic transillumination: aid in the diagnosis and treatment of pneumopericardium. Pediatrics. 1979;64:958.
  7. Bjorklund L, Lindroth M, Malmgren N, Warner A.Spontaneous pneumopericardium in an otherwise healthy full-term newborn. Acta Pediatr Scand. 1990;79:234.
  8. Pesce C, Mercurella A, Musi L, et al. Fatal cardiac tamponade as a late complication of central venous catheterization: a case report.Eur J Pediatr Surg. 1999;9:113.
  9. van Engelenburg KC, Festen C.Cardiac tamponade: a rare but life-threatening complication of central venous catheters in children.J Pediatr Surg. 1998;33:1822.
  10. Fioravanti J, Buzzard CJ, Harris JP.Pericardial effusion and tamponade as a result of percutaneous silastic catheter use. Neonatal Network. 1998;17:39.
  11. van Ditzhuyzen O, Ronayette D.Tamponnade cardiaque après catheterisme veineux central chez un nouveaune. Arch Pediatr. 1996;3:463.

P.290

 

  1. Pezzati M, Filippi L, Chiti G, et al. Central venous catheters and cardiac tamponade in preterm infants. Intensive Care Med. 2004;30:2253.
  2. Kurian MS, Reynolds ER, Humes RA, Klein MD.Cardiac tamponade caused by serous pericardial effusion in patients on extracorporeal membrane oxygenation. J Pediatr Surg. 1999;34:1311.
  3. Becker JA, Short BL, Martin GR.Cardiovascular complications adversely affect survival during extracorporeal membrane oxygenation. Crit Care Med. 1998;26:1582.
  4. Tsang TS, Freeman WK, Barnes ME, et al. Rescue echocardiographically guided pericardiocentesis for cardiac perforation complicating catheter-based procedures: The Mayo Clinic experience. J Am Coll Cardiol. 1998;32:1345.
  5. Tsang TS, Oh JK, Seward JB.Diagnosis and management of cardiac tamponade in the era of echocardiography. Clin Cardiol. 1999;22:446.
  6. Tsang TS, El-Najdawi EK, Seward JB, et al. Percutaneous echocardiographically guided pericardiocentesis in pediatric patients: evaluation of safety and efficacy. J Am Soc Echocardiogr. 1998;11:1072.
  7. Berg RA.Pulsus paradoxus in the diagnosis and management of pneumopericardium in an infant. Crit Care Med. 1990;18:340.
  8. Traen M, Schepens E, Laroche S, van Overmeire B.Cardiac tamponade and pericardial effusion due to venous umbilical catheterization. Acta Paediatr. 2005;94:626.
  9. Muhler EG, Engelhardt W, von Bernuth G.Pericardial effusions in infants and children: injection of echo contrast medium enhances the safety of echocardiographically-guided pericardiocentesis. Cardiol Young. 1998;8:506.
  10. Watzinger N, Brussee H, Fruhwald FM, et al. Pericardiocentesis guided by contrast echocardiography. Echocardiography. 1998;15:635.