Editing Pericardiocentesis

{{short description|Procedure where fluid is aspirated from the pericardium}}
{{Infobox medical intervention
|  Name        = Pericardiocentesis
|  Image       = Pericardiocentesis.jpg
|  ICD10       =
|  ICD9        = {{ICD9proc|37.0}}
|  MeshID      = D020519
|  MedlinePlus = 003872
|  OtherCodes  =
}}'''Pericardiocentesis''' ('''PCC'''), also called '''pericardial tap''', is a medical procedure where [[Pericardial fluid|fluid]] is aspirated from the [[pericardium]] (the sac enveloping the [[heart]]).

== Anatomy and physiology ==

The [[pericardium]] is a fibrous sac surrounding the heart composed of two layers: an inner visceral pericardium and an outer parietal pericardium.<ref name=":m1">{{cite journal |last1=Reyaldeen |first1=Reza |last2=Chan |first2=Nicholas |last3=Lo Presti |first3=Saberio |last4=Fava |first4=Agostina |last5=Anthony |first5=Chris |last6=Rodriguez |first6=E. Rene |last7=Tan |first7=Carmela D. |last8=Saliba |first8=Walid |last9=Cremer |first9=Paul C |last10=Klein |first10=Allan L. |title=Pericardial Anatomy, Interventions and Therapeutics: A Contemporary Review |journal=Structural Heart |date=1 November 2021 |volume=5 |issue=6 |pages=556–569 |doi=10.1080/24748706.2021.1989531 |language=en |issn=2474-8706|doi-access=free }}</ref>  The area between these two layers is known as the pericardial space and normally contains 15 to 50 mL of serous fluid.<ref name=":m2">{{cite book |last1=Roberts |first1=James |title=Roberts and Hedges' clinical procedures in emergency medicine and acute care |date=2019 |publisher=Elsevier |location=Philadelphia |isbn=978-0323547949 |edition=7th}}</ref>  This fluid protects the heart by serving as a shock absorber and provides lubrication to the heart during contraction.<ref name=":m1" /><ref name=":m2" />

The elastic nature of the pericardium allows it to accommodate a small amount of extra fluid, roughly 80 to 120 mL, in the acute setting.<ref name=":m2"/>  However, once a critical volume is reached, even small amounts of extra fluid can rapidly increase pressure within the pericardium.  This pressure can significantly hinder the ability of the heart to contract, leading to [[cardiac tamponade]].  If accumulation of fluid is slow and occurs over weeks to months, the pericardial sac can tolerate several liters of additional fluid without substantially hindering the ability of the heart to pump.<ref name=":m2"/>

== Indications ==
Indications for performing pericardiocentesis can be divided into those that are [[therapeutic]] (i.e. treating [[tamponade]]) and those that are [[diagnostic]] (i.e. [[pericardial fluid]] analysis).<ref name=":m2"/>

===Therapeutic pericardiocentesis===

==== Cardiac tamponade ====
Pericardiocentesis can be used to diagnose and treat [[cardiac tamponade]].<ref name=":4">{{Citation|last1=Gupta|first1=Pooja|title=Chapter 16 - The Pericardium and its Diseases|date=2014-01-01|url=http://www.sciencedirect.com/science/article/pii/B9780124052062000168|work=Cellular and Molecular Pathobiology of Cardiovascular Disease|pages=297–314|editor-last=Willis|editor-first=Monte S.|place=San Diego|publisher=Academic Press|language=en|doi=10.1016/b978-0-12-405206-2.00016-8|isbn=978-0-12-405206-2|access-date=2020-12-03|last2=Ibrahim|first2=Amar|last3=Butany|first3=Jagdish|editor2-last=Homeister|editor2-first=Jonathon W.|editor3-last=Stone|editor3-first=James R.|url-access=subscription}}</ref><ref name=":5">{{Citation|last1=Jneid|first1=Hani|title=Chapter 6 - Pericardial Tamponade: Clinical Presentation, Diagnosis, and Catheter-Based Therapies|date=2008-01-01|url=http://www.sciencedirect.com/science/article/pii/B978032304841550008X|work=Critical Care Medicine (Third Edition)|pages=85–92|editor-last=Parrillo|editor-first=Joseph E.|place=Philadelphia|publisher=Mosby|language=en|doi=10.1016/b978-032304841-5.50008-x|isbn=978-0-323-04841-5|access-date=2020-12-03|last2=Maree|first2=Andrew O.|last3=Palacios|first3=Igor F.|editor2-last=Dellinger|editor2-first=R. Phillip|url-access=subscription}}</ref> [[Cardiac tamponade]] is a [[medical emergency]] in which excessive accumulation of fluid within the pericardium ([[pericardial effusion]]) creates increased pressure.<ref name=":7">{{Citation|last1=Fashoyin-Aje|first1=Lola A.|title=59 - Malignancy-Related Effusions|date=2020-01-01|url=http://www.sciencedirect.com/science/article/pii/B9780323476744000591|work=Abeloff's Clinical Oncology (Sixth Edition)|pages=863–873.e4|editor-last=Niederhuber|editor-first=John E.|place=Philadelphia|publisher=Elsevier|language=en|doi=10.1016/b978-0-323-47674-4.00059-1|isbn=978-0-323-47674-4|access-date=2020-12-03|last2=Brahmer|first2=Julie R.|s2cid=198374790 |editor2-last=Armitage|editor2-first=James O.|editor3-last=Kastan|editor3-first=Michael B.|editor4-last=Doroshow|editor4-first=James H.|url-access=subscription}}</ref> This prevents the heart from filling normally with blood. This can critically decrease the amount of blood that is pumped from the heart, causing [[obstructive shock]], which can be lethal. The removal of the excess fluid reverses this dangerous process, and is often the first treatment for cardiac tamponade due to its speed.<ref name=":7" />

==== Pericarditis ====
Pericardiocentesis can relieve the symptoms of [[pericarditis]].<ref name=":4" /><ref name=":5" /> There may be a normal amount of pericardial fluid, but [[inflammation]] still causes compression of the heart. Removal of some of this fluid reduces pressure on the heart.{{cn|date=March 2021}}

===Diagnostic pericardiocentesis===
==== Analysis of pericardial fluid ====
Pericardiocentesis can also be used to analyze the fluid surrounding the heart.<ref name=":4" /><ref name=":5" /> Fluid may be analyzed to differentiate a number of conditions, including:{{cn|date=March 2021}}
* [[infection]]
* spread of [[cancer]]
* [[autoimmune]] conditions, such as [[lupus]] and [[rheumatoid arthritis]]

== Contraindications ==
===Absolute contraindications===
There are no absolute contraindications to pericardiocentesis in emergency situations where a patient is hemodynamically unstable.<ref name=":m2" /><ref name=":m3">{{cite journal |last1=Luis |first1=Sushil Allen |last2=Kane |first2=Garvan C. |last3=Luis |first3=Chris R. |last4=Oh |first4=Jae K. |last5=Sinak |first5=Lawrence J. |title=Overview of Optimal Techniques for Pericardiocentesis in Contemporary Practice |journal=Current Cardiology Reports |date=19 June 2020 |volume=22 |issue=8 |page=60 |doi=10.1007/s11886-020-01324-y |pmid=32562136 |s2cid=219854595 |url=https://pubmed.ncbi.nlm.nih.gov/32562136/ |issn=1534-3170}}</ref>

===Relative contraindications===

==== Long-term drainage ====
Pericardiocentesis is a one-off procedure, which may not be appropriate for long-term drainage. In cases where longer term drainage is needed, the cardiothoracic surgeon can create a [[pericardial window]]. This involves the removal of a section of the pericardium, and the placement of a [[chest tube]].{{cn|date=March 2021}}

==== Aortic dissection ====
Pericardiocentesis is not appropriate if cardiac tamponade is associated with [[aortic dissection]].<ref name=":5" /> In this case, there is a high risk of the procedure worsening this aortic dissection by causing [[Bleeding|haemorrhage]].<ref name=":5" />

==== Diagnosis of minor pericardial effusion ====
Pericardiocentesis is not usually useful for diagnosis of more minor [[pericardial effusion]].<ref name=":4" /><ref name=":5" />

==== Other ====
Other relative contraindications include coagulopathies, [[thrombocytopenia]], [[myocardial rupture]], severe [[pulmonary hypertension]], prior thoracoabdominal surgery, [[prosthetic heart valves]], [[pacemakers]] and other cardiac devices, inadequate visualization of the effusion on ultrasound during the procedure, and situations in which more appropriate treatment options are available.<ref name=":m2" /><ref name=":m3" />

== Procedure ==

===Overview===
The patient undergoing pericardiocentesis is [[Supine position|positioned supine]] with the head of the bed raised between a 30- and 60-degree angle. This places the heart in proximity to the [[Thoracic wall|chest wall]] for easier insertion of the needle into the pericardial sac.<ref name=":7" /><ref>{{cite book |last= Sam |first= Amir H. |author2=James T.H. Teo |title= Rapid Medicine |publisher= [[Wiley-Blackwell]] |year= 2010 |isbn= 978-1-4051-8323-9|title-link= Rapid Medicine }}</ref> For patients that are awake, a [[Local anesthetic|local anaesthetic]] is applied.<ref name=":6" /> A large needle is inserted through the skin of the chest into the pericardium, and the practitioner aspirates the [[pericardial effusion]] into a [[syringe]].<ref name=":m3" />  If needed, a drain can be placed using the [[Seldinger technique]] for continuous access.<ref name=":m3" />

===Approaches===

[[File:Pericardiocentesis locations.png|thumb|Common locations for needle insertion during pericardiocentesis procedure]]

There are multiple locations that pericardiocentesis can be performed without [[Pneumothorax|puncturing the lungs]].<ref name=":0">{{Cite web|url=http://www.sonoguide.com/pericardiocentesis.html|title=Pericardiocentesis|archive-url=https://web.archive.org/web/20160307145321/http://www.sonoguide.com/pericardiocentesis.html|archive-date=7 March 2016|url-status=dead}}</ref>
* In the past, the standard location was through the [[infrasternal angle]] and is also called subxiphoid approach.<ref name=":7" /><ref name=":0" /> The needle is inserted at an [[angle]] between 30 and 45 degrees to the chest 1 cm inferior to the left [[Infrasternal angle|xiphocostal angle]].<ref name=":m2" /><ref name=":3">{{Citation|last1=Steele|first1=Robert|title=Chapter 180 – Pericardiocentesis|date=2008-01-01|url=http://www.sciencedirect.com/science/article/pii/B9781416000877501835|work=Pediatric Emergency Medicine|pages=1259–1262|editor-last=Baren|editor-first=Jill M.|place=Philadelphia|publisher=W.B. Saunders|language=en|isbn=978-1-4160-0087-7|access-date=2020-11-16|last2=Thorp|first2=Andrea|editor2-last=Rothrock|editor2-first=Steven G.|editor3-last=Brennan|editor3-first=John A.|editor4-last=Brown|editor4-first=Lance}}</ref>
* Another location is through the 5th or 6th [[intercostal space]] at the left sternal border at the [[Cardiac notch of left lung|cardiac notch of the left lung]], and is also called as parasternal approach.<ref name=":3" /> The needle is inserted at an angle of 90 degrees to the chest.<ref name=":3" /> Some evidence suggests that this poses lower risk of vascular damage in adults.<ref name=":3" />
* With the routine use of [[ultrasound]] guidance, the apical approach is becoming more widely used.<ref name=":m2"/>  The needle is inserted at the level of the [[heart|cardiac apex]], usually between the 5th-7th [[intercostal space]].  The needle is advanced directly over the superior aspect of the [[rib]] to avoid the [[Intercostal space|neurovascular bundle]] and aimed toward the right shoulder.<ref name=":m2"/>

===Ultrasound guidance===
Pericardiocentesis should be performed with ultrasound guidance whenever possible to prevent complications.<ref name=":m2" /><ref name=":m3"/>  This allows practitioners to assess the location of the [[pericardial effusion]] and identify adjacent structures.<ref name=":m3"/>  With ultrasound guidance, an apical approach is most often used, but parasternal and subxiphoid approaches can also be used.  Agitated [[Saline (medicine)|saline]] is injected and visualized sonographically to confirm the needle placement in the pericardium.<ref name=":m3"/>

Pericardiocentesis can be performed using [[computed tomography]] (CT) imaging in cases of complex or loculated effusions or when ultrasound has failed to provide proper visualization.<ref name=":m3"/>

===Blind pericardiocentesis===
Blind pericardiocentesis can be performed in emergency settings when ultrasound is not available and typically utilizes a subxiphoid approach.<ref name=":m2" /><ref name=":m3"/>  As the needle is advanced, aspiration is performed to assess for advancement of the needle into the pericardial space.<ref name=":m3"/>  To prevent perforation of the heart, [[electrocardiography|electrocardiographic]] (ECG) monitoring might be used.  This involves using an alligator clip to attach an ECG lead to the needle.  Changes in ECG waves, such as [[ST elevation|ST segment elevations]] or PR depressions, are indicative of contact with the [[myocardium]].<ref name=":m3"/>

== Risks ==
Fewer than 1.5% of patients experience [[Complication (medicine)|complications]] from pericardiocentesis.<ref name=":1">{{Citation|last=Sorajja|first=Paul|title=17 - Pericardiocentesis|date=2018-01-01|url=http://www.sciencedirect.com/science/article/pii/B978032347671300017X|work=The Interventional Cardiac Catheterization Handbook (Fourth Edition)|pages=438–447|editor-last=Kern|editor-first=Morton J.|publisher=Elsevier|language=en|doi=10.1016/b978-0-323-47671-3.00017-x|isbn=978-0-323-47671-3|access-date=2020-11-16|editor2-last=Sorajja|editor2-first=Paul|editor3-last=Lim|editor3-first=Michael J.|url-access=subscription}}</ref> The most common complications are [[Wound|lacerations]] of [[coronary arteries]], and puncture of the [[Ventricle (heart)|left ventricle]] (with associated [[bleeding]] from both).<ref name=":1" /><ref name=":2">{{Citation|last=Sovari|first=Ali S.|title=44 - Pericardiocentesis|date=2019-01-01|url=http://www.sciencedirect.com/science/article/pii/B9780323529938000448|work=Cardiac Intensive Care (Third Edition)|pages=461–464.e1|editor-last=Brown|editor-first=David L.|place=Philadelphia|publisher=Elsevier|language=en|doi=10.1016/b978-0-323-52993-8.00044-8|isbn=978-0-323-52993-8|s2cid=260678222 |access-date=2020-11-16|url-access=subscription}}</ref> [[Echocardiography|Echocardiograms]] can help to identify complications.<ref name=":2" /> Blind approaches are typically only advised in emergencies, and a guided approach is typically preferred (using echocardiography).<ref name=":2" /><ref name=":6">{{Citation|last1=Balmanoukian|first1=Ani|title=32 - Pleural and pericardial effusions|date=2011-01-01|url=http://www.sciencedirect.com/science/article/pii/B9781437710151000321|work=Supportive Oncology|pages=354–361|editor-last=Davis|editor-first=Mellar P.|place=Saint Louis|publisher=W.B. Saunders|language=en|doi=10.1016/b978-1-4377-1015-1.00032-1|isbn=978-1-4377-1015-1|access-date=2020-12-03|last2=Brahmer|first2=Julie R.|editor2-last=Feyer|editor2-first=Petra Ch.|editor3-last=Ortner|editor3-first=Petra|editor4-last=Zimmermann|editor4-first=Camilla|url-access=subscription}}</ref>

==References==
{{Reflist}}

==External links==
* {{MedlinePlusEncyclopedia|003872}}
* {{eMedicine|med|3560}}
* [http://www.simulab.com/traumaman-procedures Trauma Man: Images of pericardiocentesis being performed on a simulator]
* [https://web.archive.org/web/20120227122303/http://cardiacsurgery.ctsnetbooks.org/cgi/content/full/3/2008/1465#Pericardiocentesis Cardiac Surgery in the Adult: Pericardial disease]

{{Cardiac surgery and other cardiovascular procedures}}

[[Category:Diagnostic cardiology]]
[[Category:Diagnostic intensive care medicine]]
[[Category:Medical diagnosis]]