PROCEDURE Pericardial Catheter Management 78 Kathleen M. Cox PURPOSE: Placement of an indwelling pericardial catheter allows for the slow and/or intermittent evacuation of fl uid from the pericardial space. An indwelling pericardial catheter also allows for the infusion of medications (e.g., antibiotics or chemotherapeutic agents) into the pericardial space.

PREREQUISITE NURSING • The pericardial catheter may be connected to a closed KNOWLEDGE drainage system ( Fig. 78-1 ). • The pericardial catheter may also be left in place to facili- • Knowledge of anatomy and physiology of the cardiovas- tate the infusion of medications (e.g., antibiotics, chemo- cular system, to include understanding of the principles of therapeutic agents) depending on the patient’ s clinical cardiac conduction, electrocardiogram (ECG) lead place- manifestations. ment, and dysrhythmia interpretation. • An indwelling catheter should usually be removed within • Knowledge and skills related to aseptic technique is 48 to 72 hours after placement to avoid risk of infection necessary. or iatrogenic pericarditis.4 Depending on the patient ’ s • Advanced cardiac life support (ACLS) knowledge and underlying condition, the catheter may be left in place for skills. longer periods to facilitate resolution of pericardial effu- • The pericardial space normally contains 20 to 50 mL of sion, , or infusion of medication. 8 Peri- fl uid. cardial catheters should be removed immediately for any • Pericardial fl uid has electrolyte and protein profi les similar signs of infection or an abrupt rise in white blood cell to plasma. count. 9 • is generally defi ned as the accumula- • Pericardial catheters are generally removed when the peri- tion of fl uid within the pericardial sac that exceeds the cardial drainage decreases to less than 25 to 30 mL for the stretch capacity of the , generally more than preceding 24-hour period.6 50 to 100 mL.12 • Extended catheter drainage is associated with a reduction • Intrapericardial fl uid accumulation can be acute or chronic of the reoccurrence of cardiac tamponade compared with and therefore it varies in presentation of symptoms. Acute a single in patients with pericardial effusions are usually a rapid collection of fl uid occurring effusion related to malignancy.10 over minutes to hours and may result in hemodynamic compromise with volumes less than 250 mL. 8 Chronically EQUIPMENT developing effusions occurring over days to weeks allow for hypertrophy and distention of the fi brous pericardial • Pericardial catheter membrane. Patients with chronic effusions may accumu- • Sterile drapes: 4 small drapes and a full-body drape late greater than or equal to 2000 mL of fl uid before • Sterile and nonsterile gloves, gowns, masks, protective exhibiting symptoms of hemodynamic compromise.8 eyewear • Symptoms of cardiac tamponade are nonspecifi c, so the • Sterile 0.9% normal saline (NS) solution for irrigation and diagnosis relies on clinical suspicion and associated signs sterile basin and symptoms. Acute pericardial effusions are usually a • Sterile syringes: 3-, 5-, 30-, or 60-mL Luer-Lok result of trauma, myocardial infarction, or iatrogenic injury, • Sterile 1000-mL vacuum bottle available for the initial whereas chronic effusions can result from conditions such procedure as bacterial or viral pericarditis, cancer, autoimmune dis- • Antiseptic solution (e.g., 2% chlorhexidine-based orders, uremia, etc.2 With a decrease in cardiac output, the preparation) patient often develops chest pain, dyspnea, tachycardia, • Sterile 4 × 4 gauze tachypnea, pallor, cyanosis, impaired cerebral and renal • Sterile transparent occlusive dressing function, diaphoresis, hypotension, neck vein distention, • Adhesive tape distant or faint sounds, and pulsus paradoxus.6 • Sterile three-way Luer-Lok stopcock with nonvented caps • Pericardiocentesis is an effective treatment for pericardial and replacement caps effusion (see Procedures 42 and 43 ). For chronic or rapidly • Drainage tubing accumulating effusions, an indwelling pericardial catheter • Pericardial drainage bag may be placed for continuous or intermittent drainage of Additional equipment, to have available as needed, includes excess fl uid. the following:

678 78 Pericardial Catheter Management 679

Pericardial signs and symptoms (e.g., dyspnea, dull ache or pressure catheter To chest within the chest, dysphagia, cough, tachypnea, hoarse- ness, hiccups, or nausea).5,6 Rationale: Early recognition 3-way of signs and symptoms of recurrent pericardial effusion stopcock Infusion may prompt detection of a potentially life-threatening port problem.

Drainage tubing PATIENT ASSESSMENT AND PREPARATION Patient Assessment Drainage • Assess the patient ’ s neurological, cardiovascular, and bag hemodynamic status including heart rate, cardiac rhythm,

heart sounds (S1 , S 2, rubs, murmurs), blood pressure (BP), mean arterial pressure, peripheral pulses, oxygen saturation via pulse oximetry, respiratory status, and if available, pressures, pulmonary Emptying artery occlusion pressure (PAOP), right-atrial pressure port (RAP), cardiac output (CO) and cardiac index (CI), and systemic vascular resistance. Rationale: Provides Figure 78-1 Indwelling pericardial catheter system. (From baseline data. Hammel WJ: Care of patients with an indwelling pericardial • Assess the patient for dyspnea, tachypnea, tachycardia, catheter; Crit Care Nurs 18[5]:40–45, 1998.) muffl ed heart sounds, precordial dullness to percussion, or impaired consciousness; hypotension (systolic BP • Anticoagulant fl ush available for dwell if prescribed (i.e., < 100 mm Hg or decreased from patient ’ s baseline); heparin) increased jugular venous pressure/jugular distention; • Cytotoxic disposal receptacle (when chemotherapeutic or pulsus paradoxus (inspiratory decrease in systolic BP cytotoxic agents are prescribed; also used to avoid aero- amplitude) greater than 12 to 15 mm Hg; equalization of solization of the medication once disconnected from the RAP, PAOP, and pulmonary artery diastolic pressure; and patient) decreased CO/CI.2 Rationale: Assessment of these signs • Emergency cart (defi brillator, emergency respiratory and symptoms of possible cardiac tamponade is essential equipment, emergency cardiac medications) for identifi cation of potential complications and catheter patency. PATIENT AND FAMILY EDUCATION • Determine the patient ’ s allergy history (e.g., heparin, anti- septic solutions). Rationale: This assessment decreases • Explain to the patient and family the reason necessitating the risk for allergic reactions by avoiding known aller- the indwelling pericardial catheter (e.g., relief of pressure genic products. on the heart). Rationale: Communication of pertinent information helps the patient and family to understand the Patient Preparation procedure and the potential risks and benefi ts, subse- • Confi rm that the patient and family understand preproce- quently reducing anxiety and apprehension.1 dural teaching by having them verbalize understanding. • Discuss potential discomfort the catheter may cause with Clarify key points by reinforcing important information inspiration and the insertion site. Reassure patient and and answer all questions. Rationale: Preprocedure com- family that pain medication will be prescribed and admin- munication provides a framework of patient expectations, istered as necessary. Rationale: This explanation prepares enhances cooperation, and reduces anxiety.1 and informs the patient of the pain-management plan and • Verify that the patient is the correct patient using two reassures the patient that pain management is a priority. patient-specifi c identifi ers. Rationale: The nurse should • Instruct the patient and family about the patient’ s risk for always ensure the correct identifi cation of the patient for recurrent pericardial effusion, describing the potential the intended intervention for patient safety. 680 Unit II Cardiovascular System

Procedure for Pericardial Catheter Management Steps Rationale Considerations General Management of the Patient With a Pericardial Catheter Without a Drainage System 1 . HH 2 . PE Consider putting a mask on the patient during the actual procedure if the patient is not intubated (in a contained system), especially if the patient has methicillin-resistant Staphylococcus aureus (MRSA)– positive results on nasal swab or known colonization. 3. Assist the physician or advanced Provides assistance as needed. The pericardial catheter may be practice nurse with the inserted in the operating room, in a pericardiocentesis procedure (see special procedure environment Procedures 42 and 43 ). (e.g., cardiac catheterization laboratory or interventional laboratory), or at the bedside. 4. Determine that the connections Ensures that the integrity of the At the completion of the pericardial between the pericardial catheter system is intact. tap, the stopcock is turned off to and the stopcock are tight. the patient and a sterile nonvented cap is placed on the stopcock port. 5. Observe the drainage of pericardial Ensures pericardial catheter patency. Pericardial fl uid is commonly fl uid for color, amount, and The presence of fi brin matrix in the straw-colored, serous drainage. A consistency. drainage can result in obstruction of two-dimensional (2D) or Doppler the catheter and be problematic for echocardiogram can be performed future manual taps. after the pericardiocentesis to assess for reaccumulation of pericardial fl uid.8 6. Perform catheter site care. Prevents infection. A . HH B . PE C. Remove the dressing and Allows for site assessment and discard it in an appropriate prepares for site care. receptacle. D. Assess the skin surrounding the Assesses for signs and symptoms of catheter-insertion site. infection. E. Remove and discard the Maintains aseptic technique. nonsterile gloves in an appropriate receptacle. F . HH G. Apply sterile gloves. Prepares for the procedure. H. Cleanse the skin around the Reduces the rate of recolonization of pericardial catheter-insertion skin microfl ora. The Centers for site using a back and forth Disease Control and Prevention motion while applying friction (CDC) do not have a specifi c for 30 seconds with an recommendation for care of antiseptic solution (e.g., 2% pericardial catheters or site care. chlorhexidine-based solution)3,4 and allow time to dry. (Level D * ) I. Ensure that the catheter and Reduces the possibility of stopcock are securely anchored displacement. to the chest.

* Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations. 78 Pericardial Catheter Management 681

Procedure for Pericardial Catheter Management—Continued Steps Rationale Considerations J. Apply a sterile, occlusive Provides a sterile environment. dressing over the catheter Identifi es the last dressing change. insertion site. Label the dressing with the date, time, and initials of the person performing the dressing change. K. Remove PE and discard used supplies in the appropriate receptacles. L . HH 7 . If pericardial fl uid removal is Removes excess pericardial fl uid and Follow institutional standards desired, aspirate pericardial fl uid relieves symptoms of cardiac regarding personnel permitted to every 4–6 hours as prescribed or as tamponade; ensures catheter aspirate and fl ush pericardial often as is clinically indicated patency. catheters (e.g., registered nurses, through the three-way stopcock advanced practice nurses, using sterile technique. 8 physicians). Consider placing a mask on the patient during the procedure if the patient is not intubated. Pericardial fl uid samples may be collected for select diagnostic tests (e.g., protein, glucose, hematocrit, white blood cell count, bacterial or fungal cultures). A . HH B . PE C. Ensure the stopcock is turned Prepares for fl uid removal. off to the patient and then remove the nonvented cap from the infusion port of the three-way stopcock. D. Cleanse the infusion port cap at Decreases the risk for infection. the top of the stopcock with an antiseptic solution for 15 seconds and allow to dry. 3,4,9,11 E. Attach a sterile, 60-mL Prepares for fl uid removal. Luer-Lok syringe to the three-way stopcock. F. Turn the stopcock open to the Permits aspiration of fl uid. syringe and patient. G. Gently aspirate pericardial fl uid Gentle removal is necessary to avoid while monitoring patient pericardial or myocardial injury. response. H. After completion of the fl uid Stops pericardial drainage. withdrawal, turn the stopcock off to the patient. I. Disconnect the specimen Removes the specimen. syringe from the stopcock. J. Connect the fl ush syringe to the Prepares the equipment for fl ushing. stopcock. K. Turn the stopcock open to the Clears the pericardial catheter and Monitor vital signs and ECG tracing syringe and patient and gently promotes catheter patency. while fl ushing the pericardial fl ush the pericardial catheter catheter to assess patient response with 2–5 mL of sterile NS to the procedure; follow institution solution or heparinized saline standard for administration of dwell solution as prescribed. solution. Procedure continues on following page 682 Unit II Cardiovascular System

Procedure for Pericardial Catheter Management—Continued Steps Rationale Considerations L. Turn the stopcock off to the Removes equipment. patient and disconnect the fl ush syringe M. Carefully place a new sterile Maintains sterile, closed system and nonvented cap on the stopcock. reduces risk of infection. N. Measure the amount of Records amount of drainage. drainage. O. Remove PE and discard used supplies in the appropriate receptacles. P . HH 8 . If the pericardial catheter is Follow institutional standards blocked or obstructed to fl ow: regarding personnel permitted to aspirate and fl ush pericardial catheters (e.g., registered nurses, advanced practice nurses, physicians). A . HH B . PE C. Examine the catheter to Relieves mechanical obstruction to determine whether there is an fl ow. external mechanical cause of the pericardial catheter blockage, and correct if present. Consider the following: i. Kinks in tubing. ii. Tubing may be compressed underneath patient. iii. Turn or reposition patient to facilitate fl o w . D. Assess for loose tubing Ensures intact drainage system. connections and, if loosened, tighten connections. E. Determine correct positioning Facilitates unobstructed fl uid of the stopcock. If needed, drainage. correct the stopcock position. F. If the previous steps do not Attempts to relieve the obstruction. correct the obstruction to fl ow, do the following: i. Turn the stopcock off to Prepares the equipment. the patient and remove the cap from the infusion port of the stopcock. ii. Clean the infusion port of Decreases the risk of infection. the stopcock with an alcohol swab for 15 seconds and allow to dry. 3,4,9,11 iii. Attach the syringe for the Prepares the equipment. fl ush and turn the stopcock open to the patient. 78 Pericardial Catheter Management 683

Procedure for Pericardial Catheter Management—Continued Steps Rationale Considerations iv. Turn the stopcock open to Attempts to improve pericardial Monitor vital signs and ECG tracing the syringe and patient and catheter patency. Heparinized saline to determine patient response while gently fl ush the pericardial solution may be used for a dwell if fl ushing the pericardial catheter. catheter with 2–5 mL of the drainage tends to be serous or Follow institutional standard for sterile NS solution or fi brous in consistency.7 administration of dwell solution, if heparinized saline solution prescribed. as prescribed (use NS if the patient is sensitive to heparin). v. Gently attempt to aspirate Allows for aspiration of fl ush solution Deduct the volume of fl ush solution fl ush solution. and pericardial fl uid. from the total volume for accurate measurement of pericardial fl uid. vi. Determine whether the Assesses the proper functioning of the Monitor vital signs and ECG. pericardial catheter is system. patent and fl uid is draining. vii. If the above measures do Additional interventions are indicated. not remove the catheter blockage, notify the physician or advanced practice nurse immediately. 9 . If medications are prescribed for Follow institutional standards for PE infusion into the pericardium: when administering cytotoxic or antineoplastic medications. Follow institutional standards regarding personnel permitted to instill medications into the pericardial sac. A . HH B . PE C. Review the prescribed Ensures the accuracy of medication medication, dose, method of administration and prepares the delivery, amount, and time for equipment. dwell. Assemble the medication, tubing, pump or syringe and two fl ush syringes of 0.9% NS (2–5 mL each).3,7 D. Ensure that the stopcock is off Prepares for the procedure. to the patient and remove the cap from the infusion port. E. Clean the infusion port of the Reduces the risk of infection. stopcock with an alcohol swab for 15 seconds and allow to dry. 3,4,9,11 F. Attach a fl ush syringe and turn Ensures catheter patency. the stopcock open to the patient. Establish patency of the catheter by gentle infusion and withdrawal of 0.9% NS. G. Turn the stopcock off to the Prepares the equipment. patient and disconnect the fl ush syringe. Procedure continues on following page 684 Unit II Cardiovascular System

Procedure for Pericardial Catheter Management—Continued Steps Rationale Considerations H. Attach the prescribed Administers the medication as Infusion of the medication may medication (either infusion or prescribed. activate signs and symptoms of syringe). With the use of a cardiac tamponade. 11 syringe for delivery, gently Monitor vital signs and ECG tracing instill the medication. If using while infusing the medication to an infusion pump, set the assess response of the patient. appropriate medication infusion If the patient has any abnormal signs rate. or symptoms, stop the infusion and notify the advanced practice nurse or the physician. I. Turn the stopcock off to the Stops the medication administration. patient when the medication delivery is complete. J. Disconnect the tubing or Removes the equipment. syringe. K. Attach a fl ush syringe of 0.9% Prepares the equipment. NS. L. Turn the stopcock open to the Ensures the medication is completely patient and gently fl ush the in the pericardium and none catheter. remains in the catheter. M. Turn the stopcock off to the Closes and maintains the integrity of patient and apply a sterile the system. nonvented cap to the infusion port. N. Allow the medication to dwell Allows time for the medication to act. for the prescribed time. O. When the dwell time is Prepares the equipment. complete, remove the infusion port cap and attach a syringe large enough to retrieve the medication plus the pericardial fl uid accumulation. P. Gently withdraw the Removes the medication. Volume of the retrieved fl uid should medication and pericardial be equivalent to the volume of drainage. medication that was instilled, plus the fl ush solution and additional pericardial fl uid that accumulated during the dwell time. Q. Turn the stopcock off to the Removes the equipment. patient and disconnect the syringe. R. Attach a fl ush syringe of Prepares the equipment. 2–5 mL of 0.9% NS with or without heparin as prescribed.3,8 S. Turn the stopcock open to the Clears the pericardial catheter. patient and instill the 0.9% NS or heparin fl ush. T. Turn the stopcock off to the Closes the pericardial catheter system patient, remove the fl ush and maintains the integrity of the syringe, and apply a sterile closed system. nonvented cap to the infusion port. 78 Pericardial Catheter Management 685

Procedure for Pericardial Catheter Management—Continued Steps Rationale Considerations U. Remove PE and discard used Discard any antineoplastic or supplies in the appropriate cytotoxic agent, tubing, and fl ush receptacles. syringes in the designated biohazard receptacle. V. HH General Management of the Patient With a Pericardial Catheter Closed Drainage System 1 . HH 2 . PE 3. Assist the physician or advanced Provides assistance as needed. The pericardial catheter may be practice nurse with the inserted in the operating room, in a pericardiocentesis (see Procedures special procedure environment 42 and 43 ). (e.g., cardiac catheterization laboratory or interventional laboratory), or at the bedside. 4. Determine that the connections Ensures the integrity of the system. At the completion of the pericardial between the pericardial catheter tap, a nonvented sterile cap is and the stopcock are tight. placed on the stopcock port and the stopcock is turned off to the patient or open to drainage as prescribed. 5. Position the drainage-collection Ensures pericardial catheter patency. Pericardial fl uid is commonly receptacle lower than the catheter- The presence of fi brin matrix in the straw-colored, serous drainage. insertion point to facilitate drainage can result in obstruction of A 2D or Doppler echocardiogram can drainage, and observe the fl uid for the catheter and be problematic for be performed after the color, amount, and consistency. future manual taps. pericardiocentesis to assess for reaccumulation of pericardial fl uid.8 6. Perform catheter-site care. Helps prevent infection. Observe the site for any evidence of drainage and notify the physician or advanced practice nurse of this fi nding. A . HH B . PE C. Remove the dressing and Allows for site assessment and discard it in an appropriate prepares for site care. receptacle. D. Assess the catheter and Assesses for signs and symptoms of insertion site. infection. E. Remove and discard the Maintains aseptic technique. nonsterile gloves in an appropriate receptacle. F . HH G. Apply sterile gloves and establish a sterile fi eld. H. Cleanse the skin around the Reduces the rate of colonization of pericardial catheter-insertion skin microfl ora. The Centers for site using a back and forth Disease Control and Prevention motion while applying friction (CDC) do not have a specifi c for 30 seconds with an recommendation for care of antiseptic solution (e.g., 2% pericardial catheters or site care. chlorhexidine-based solution).3,4 Allow the antiseptic to remain on the insertion site and to air dry completely.9,11 (Level D * )

*Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations.

Procedure continues on following page 686 Unit II Cardiovascular System

Procedure for Pericardial Catheter Management—Continued Steps Rationale Considerations I. Determine whether the catheter Ensures a secure system. and stopcock are securely anchored to the chest. J. Apply a sterile, occlusive Provides a sterile environment. dressing over the catheter- Identifi es the last dressing change. insertion site. Label the dressing with the date, time and initials of the person performing the dressing change. K. Remove PE and discard used supplies in the appropriate receptacle. L . HH 7 . If pericardial fl uid removal is Removes pericardial fl uid. Follow institutional standards desired: intermittently or regarding personnel permitted to continuously drain the pericardial aspirate and fl ush pericardial fl uid as prescribed by turning the catheters (e.g., registered nurses, stopcock off to the infusion port advanced practice nurses, and open between the patient and physicians). the drainage bag (see Fig. 78-1 ). A . Intermittent drainage: If intermittent drainage is prescribed, the stopcock is usually off to the patient and opened every 4–6 hours to drainage or as clinically indicated with Doppler scan or 2D echocardiogram and patient presentation until the accumulation of fl uid is resolved (follow the prescribed regimen). B . Continuous drainage: If continuous drainage is prescribed, the stopcock remains open between the patient and the drainage bag and off to the infusion port (follow the prescribed regimen). C. Empty the pericardial drainage Reduces the possibility of Pericardial fl uid samples may be bag every 8 hours or sooner if colonization in the bag and the collected for selected diagnostic prescribed. potential refl ux of fl uid to the tests. patient. i . HH ii. PE iii. Turn the stopcock off to Reduces risk of pneumopericardium. the patient. iv. Open the emptying port of Discard drainage. the drainage bag and drain the pericardial fl uid into a receptacle for measurement and waste disposal. 78 Pericardial Catheter Management 687

Procedure for Pericardial Catheter Management—Continued Steps Rationale Considerations v. Close the port and secure Closes and maintains integrity of the the drainage bag. system. vi. Resume the prescribed Continues prescribed treatment. drainage mode. D. After completion of Prepares for the procedure. intermittent fl uid drainage, temporarily turn the stopcock off to the patient for the fl ush procedure. i . HH ii. PE iii. Remove the infusion port Reduces risk of infection. cap and cleanse the infusion port at the top of the stopcock with an antiseptic solution for 15 seconds and allow to dry.3,4,9,11 iv. Connect the fl ush syringe, Clears the pericardial catheter and turn the stopcock open to maintains catheter patency. the syringe and patient, and gently fl ush the pericardial catheter with 2–5 mL of sterile NS solution or heparinized saline solution as prescribed (use NS if the patient is sensitive to heparin). v. Turn the three-way Maintains integrity of the closed stopcock off to the patient system and minimizes risk of and disconnect the fl ush pneumopericardium. syringe. vi. Place a new sterile Maintains asepsis. nonvented cap on the infusion port. vii. Remove PE and discard used supplies in appropriate receptacles. viii. HH 8 . If the pericardial catheter is Follow institutional standards blocked or obstructed to fl ow: regarding personnel permitted to aspirate and fl ush pericardial catheters (e.g., registered nurses, advanced practice nurses, physicians). A . HH B . PE C. Determine whether the Facilitates drainage by gravity. drainage system is lower than the insertion point and reposition if needed. Procedure continues on following page 688 Unit II Cardiovascular System

Procedure for Pericardial Catheter Management—Continued Steps Rationale Considerations D. Examine the catheter to Relieves mechanical obstruction to determine whether there is an fl ow. external mechanical cause of the pericardial catheter blockage, and correct if present. Consider the following: i. Kinks in tubing. ii. Tubing may be compressed underneath patient. iii. Turn or reposition patient to facilitate fl o w . E. Assess for loose tubing Ensures intact drainage system. connections and, if loosened, tighten connections. F. Determine correct positioning Facilitates unobstructed fl uid of the stopcock. If needed, drainage. correct the stopcock position. G. If the previous steps do not correct the obstruction to fl ow, do the following: i. Remove the infusion port Decreases the risk of infection. cap and cleanse the infusion port at the top of the stopcock with an antiseptic solution for 15 seconds and allow to dry. 3,4,9,11 ii. Connect the fl ush syringe, Attempts to improve pericardial Monitor vital signs and ECG tracing turn the stopcock open to catheter patency. Heparinized saline while fl ushing the pericardial the syringe and patient, and solution may be used for a dwell if catheter to assess patient response. gently fl ush the pericardial the drainage tends to be serous or Follow institutional standards for catheter with 2–5 mL of fi brous in consistency.7 administration of dwell solution, if sterile NS solution or prescribed. heparinized saline solution as prescribed (use NS if patient is sensitive to heparin). iii. Turn the stopcock off to Allows drainage of fl ush solution and Volume of the drained fl uid should be the infusion port and allow pericardial fl uid. equivalent to the volume of the the fl uid to passively drain fl ush solution and additional or turn the stopcock off to accumulated pericardial fl uid; the drainage bag and gently deduct the amount of fl ush used to attempt to aspirate the fl ush accurately measure output. solution through the attached syringe. iv. Determine whether the Assesses patency of the system. pericardial catheter is draining and patent. v. If the previous measures Ensures integrity of the system and Ensure the stopcock is off to the are ineffective for drainage may facilitate drainage. patient at the time of the change. but the catheter itself is patent, consider changing the tubing and the drainage-bag system. 78 Pericardial Catheter Management 689

Procedure for Pericardial Catheter Management—Continued Steps Rationale Considerations vi. After the tubing/bag Determines whether the system is change, assess the patency functioning. of the system. vii. If these measures do not Additional interventions are Accumulation of fl uid in the remove the catheter necessary. pericardium without the possibility blockage, notify the of drainage may result in physician or advanced tamponade. practice nurse immediately. viii. Remove PE and discard used supplies in appropriate receptacles. ix. HH 9 . If medications are prescribed for Follow institutional standards for PE infusion into the pericardium: when administering cytotoxic or antineoplastic medications. Follow institutional standards regarding personnel permitted to instill medications into the pericardial sac. A . HH B . PE C. Review the prescribed Ensures the accuracy of medication medication, dose, method of administration. delivery, amount, and time for dwell. Assemble the medication, tubing, pump or syringe, and two fl ush syringes of 0.9% NS (2–5 mL each).3,7 D. Turn the stopcock off to the Reduces risk of infection. patient, remove the infusion port cap, and cleanse the infusion port at the top of the stopcock with an antiseptic solution for 15 seconds and allow to dry.3,4,9,11 E. Turn the stopcock off to the Prevents inadvertent instillation of drainage bag. Attach the medication into the drainage bag. prescribed medication (either infusion or syringe). F. With the use of a syringe for Administers the medication. Infusion of the medication may delivery, gently instill the activate signs and symptoms of medication as prescribed. cardiac tamponade. 11 If using an infusion pump, set Monitor vital signs and ECG tracing the appropriate medication- while infusing the medication to infusion rate. (Patency of the assess patient response. catheter is established by virtue If the patient has abnormal signs and of evident drainage. symptoms, stop the infusion and If there is a question about notify the advanced practice nurse catheter patency, follow the or the physician. fl ush procedure listed in the medication infusion section of General Management of the Patient with a Pericardial Catheter without a Drainage System.) Procedure continues on following page 690 Unit II Cardiovascular System

Procedure for Pericardial Catheter Management—Continued Steps Rationale Considerations G. If the medication is to dwell in the pericardial space before reestablishment of pericardial drainage: i. Turn the stopcock off to the patient at the completion of the infusion. ii. Disconnect the medication syringe or tubing. iii. Attach a syringe with 2–5 mL of 0.9% NS fl ush and turn the stopcock off to the drainage bag. iv. Gently fl ush the catheter Ensures that the medication is and turn the stopcock off instilled in the pericardial space and to the patient for the does not lie in the catheter. completion of the dwell time as prescribed. v. Disconnect the syringe and close system with a sterile nonvented cap. vi. After the dwell time is Allows pericardial drainage to The drain time should allow for all of complete, turn the stopcock resume. the medication to exit the off to the infusion port and pericardium. open to drainage. vii. Measure the amount of the Volume of the drained fl uid should be solution infused and the equivalent to the volume of the drainage collected. medication instilled, the fl ush solution, and additional accumulated pericardial fl uid; deduct the amount of medication infused and fl ush used to accurately measure output. viii. Resume the prescribed drainage mode: continuous or intermittent. If intermittent, follow the prescription for the drain time after infusion. a. Once the drain time is Reduces the risk for infection. completed, clean the infusion port of the stopcock with an alcohol swab for 15 seconds. 3,4,9,11 b. Connect the fl ush Helps to maintain the pericardial syringe, turn the catheter patency. stopcock open to the syringe and patient, and gently fl ush the pericardial catheter with 2–5 mL of sterile NS solution or heparinized saline solution as prescribed (use NS if the patient is sensitive to heparin). 78 Pericardial Catheter Management 691

Procedure for Pericardial Catheter Management—Continued Steps Rationale Considerations c. Turn the stopcock off to Maintains integrity of the system. the patient until the next time the patient is due for intermittent drainage. d. Remove PE and discard used supplies in appropriate receptacles. e . HH

Expected Outcomes Unexpected Outcomes • Patent pericardial drainage system • Infection • Resolution of pericardial effusion • Pain • Hemodynamic stability • Catheter obstruction • Patient free of infection • Reaccumulation of pericardial fl uid • Patient free of pain and anxiety • Cardiac tamponade and hemodynamic instability • Medications administered as prescribed • Dysrhythmias • Cardiac arrest

Patient Monitoring and Care Steps Rationale Reportable Conditions These conditions must be reported if they persist despite nursing interventions 1. Perform cardiovascular and Assesses for signs of cardiac • Signs of cardiac tamponade: hemodynamic assessments at least tamponade and determines dyspnea, tachypnea, tachycardia, every 60 minutes and as patient hemodynamic stability. hypotension, increased jugular condition necessitates, or as venous pressure, pulsus paradoxus, prescribed muffl ed heart sounds, precordial dullness to percussion, altered level of consciousness. • Equalization of RAP, PAOP • CI < 2.5 L/min/m 2 • Dysrhythmias 2. Assess the patency of the Pericardial catheter blockage may • Inability to obtain pericardial pericardial catheter: predispose the patient to excessive drainage or cessation of pericardial A. Without a closed drainage accumulation of pericardial fl uid drainage system, every 4–6 hours, and that may lead to cardiac tamponade • Signs and symptoms of cardiac as needed or as prescribed. and/or hemodynamic instability. tamponade or hemodynamic B. With a closed drainage system, instability every hour, and as needed or as • Evidence of accumulation of prescribed. pericardial fl uid on Doppler or 2D 3. Assess the amount and type of Provides information regarding the • Change in the amount, color, or fl uid draining from the pericardial continued need for the catheter and consistency of pericardial drainage catheter. potential problems. from patient ’ s baseline 4. Change the pericardial catheter Provides an opportunity to assess for dressing every 24 hours.4 signs and symptoms of infection. • Elevated white blood cell counts Infective pericarditis is associated • Elevated temperature with increased mortality and • Signs and symptoms of infection at morbidity rates. 10 the insertion site (e.g., pain, The CDC recommends replacing erythema, drainage, etc.) dressings on intravascular catheters when the dressing becomes damp, loosened, or soiled or when inspection of the site is necessary.4 Procedure continues on following page 692 Unit II Cardiovascular System

Patient Monitoring and Care —Continued Steps Rationale Reportable Conditions 5. If in use, change the pericardial Reduces the risk of infection. tubing and drainage bag every 72 hours.3,8 6. Follow institutional standards for Identifi es need for pain interventions. • Continued pain despite assessing pain and administer The patient may experience chest interventions analgesia as prescribed. pain or pleuritic type pain while the pericardial catheter is in place. 7. Identify parameters that Facilitates early removal of the • Pericardial drainage < 25–30 mL demonstrate clinical readiness for pericardial catheter and reduces the over the previous 24 hours 12 removal of the indwelling risk of infection. • Hemodynamic stability as pericardial catheter.8,13 evidenced by systolic BP > 100 mm Hg, CI > 2.5 L/min/m 2 , absence of pulsus paradoxus, no equalization of RAP, PA diastolic pressure, and PAOP • Absence of pericardial effusion on Doppler or 2D echocardiography 13 8. Identify situations in which the Additional interventions may be • Hemodynamic instability pericardial effusion cannot be needed. • Continued pericardial effusion resolved with use of pericardial drainage via tap or closed system.10

Documentation Documentation should include the following: • Patient and family education • Volumes of injectate or aspirate • Universal Protocol requirements • Characteristics of the pericardial drainage: color, • Patient tolerance of the indwelling pericardial catheter consistency, and/or changes • Dressing, tubing, and drainage bag changes • Hemodynamic status • Amount of pericardial drainage each shift, including • Pain assessment, interventions, and effectiveness net volumes when catheter is fl ushed or medications • Occurrence of unexpected outcomes/treatments are infused • Nursing interventions

References and Additional Readings For a complete list of references and additional readings for this procedure, scan this QR code with any freely available smartphone code reader app, or visit http://booksite.elsevier.com/9780323376624 .