Ultrasound-Guided Pericardiocentesis

Ultrasound-Guided Pericardiocentesis

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A phased array probe is used to reveal a very large pericardial effusion around this patient's heart.  The pericardial fusion measures approximately two centimeters in diameter on the anterior surface of the heart.  Now we're prepping the anterior chest wall with chlorhexidine swabs.  Now we're applying a sterile drape on the anterior chest wall with the center of the drape along the fourth intercostal space in the parasternal area.  We're applying a sterile sheath around a linear array probe, and now we're applying some sterile rubber bands to keep the sheath in place.  Sterile ultrasound gel is then used so that we can do real time ultrasound.  Here we're seeing the pericardial effusion over the beating heart in the anterior [ph 01:46] edge of the monitor.

Now we're drawing up 1 percent lidocaine which will be used for local anesthesia.  Here we have another view of the pericardial effusion using the linear array probe.  We're inserting the local anesthesia right at the tip of the linear array probe as a skin wheel and numbing up the subcutaneous tissue.  Now we will use an introducer needle using an enplane technique on the – at the edge of the linear array probe directing the needle parallel to the probe and then about a 45 degree angle to the skin.  As we insert the introducer needle we're looking at the ultrasound monitor and we're visualizing the needle entering from the skin all the way into the pericardial space.  You have a good visualization of the needle that is almost into the pericardial space at this point as it is carefully advanced forward until we have returned now of blood stained pericardial fluid.

The needle hub is grasped carefully and wire is threaded through the needle, as is shown here.  The wire is threading without any resistance.  The needle is then withdrawn and a scalpel cut is made over the wire and we have to assure that the wire can move freely in the stab wound.  We're now dilating a subcutaneous tract through the skin and into the subcutaneous tissue and into the pericardial sac.  You will advance the dilators with a twisting motion.  First a smaller dilator will be used followed by a larger dilator.  Now the larger dilator is being introduced over the wire.  Make sure you grasp the wire along the proximal end of the dilator so you do not lose the wire into the pericardial sac.  Also make sure you do not pull out the wire when you pull the dilator back.

Now the pericardiocentesis catheter is placed over the wire.  Make sure you can grasp the wire on the opposite end of the pericardiocentesis catheter before you start to advance the pericardiocentesis catheter into the pericardial sac.  Now the pericardiocentesis catheter is being advanced over the wire, again with a twisting motion as it is gradually advanced until you have only about six inches of catheter outside of the skin.  The wire is now being withdrawn back into its sheath and the wire will be fully removed leaving the pericardiocentesis catheter in place.

A 20 milliliter syringe is then used to collect some of the fluid which will be poured into a container in a well outside of the sterile field.  We know that this is pericardial fluid and not myocardial fluid because the blood stained fluid will not clot if it's pericardial fluid which was the case in this procedure.  We're now attaching draining tubing with the port that has two lines coming off of it attached to a 16 milliliter lu alat locked syringe.  The shorter line is then connected to the pericardiocentesis catheter and the longer line is connected to a sterile bag.  The one-way stopcock on this drainage tubing allows you to aspirate blood into the syringe and then push blood from the syringe into the tubing without changing the direction of a three-way stopcock.

Here you can see blood tinged.  Pericardial fluid is being manually drained and then pushed into the sterile collection bag.  As we aspirate the pericardial fluid we can use the linear array probe to gradually see that the volume of the pericardial fluid is steadily decreasing which gives us reassurance that this is indeed aspiration of pericardial fluid and not intracardiac fluid.  Now we have almost no pericardial fluid left when we're meeting resistance with aspiration.  We slowly pull back the pericardial catheter with still resistance in fluid which means that there's almost no fluid left, and then the pericardial catheter can be withdrawn from the skin.

Now we're going to use a O silk suture to place a single interrupted stitch and close the stab incision.  Now we're going to go back and use the phased array probe the view the heart and you can see that there is only a very thin rim of pericardial effusion left after the pericardiocentesis.