78 Pericardial Catheter Management 679

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, cardiac tamponade, 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 • Pericardial effusion 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 pericardium, 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 pericardiocentesis 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 heart 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, pulmonary artery 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, antiseptic 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

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