PROCEDURE (Perform) 42 Kathleen M. Cox PURPOSE: Pericardiocentesis is the removal of excess fl uid from the pericardial sac for identifi cation of the etiology of by fl uid analysis (diagnostic pericardiocentesis) and/or prevention or treatment of (therapeutic pericardiocentesis).

result of trauma, myocardial infarction, or iatrogenic PREREQUISITE NURSING injury, whereas chronic effusions can result from condi- KNOWLEDGE tions such as bacterial or viral , , autoim- mune disorders, uremia, etc.2 With a decrease in cardiac • Advanced cardiac life support (ACLS) knowledge and output, the patient often develops chest pain, dyspnea, skills are required. tachycardia, tachypnea, pallor, cyanosis, impaired cere- • Knowledge and skills related to sterile technique are bral and renal function, diaphoresis, hypotension, neck needed. vein distention, distant or faint sounds, and pulsus • Clinical and technical competence in the performance of paradoxus.4 pericardiocentesis is required. • The amount of fl uid in the is evaluated • Knowledge of cardiovascular anatomy and physiology is through chest radiograph, two-dimensional echocardio- needed. gram, (ECG), and clinical fi ndings. • The pericardial space normally contains 20–50 mL of Chest x-rays may not be diagnostically signifi cant in fl uid. patients with acute traumatic tamponade. 6 • Pericardial fl uid has electrolyte and protein profi les similar • Pericardiocentesis to remove fl uid from the pericardial to plasma. sac is performed therapeutically to relieve tamponade or • Pericardial effusion is generally defi ned as the accumula- to diagnose the etiology of the effusion. An acute tampon- tion of fl uid within the pericardial sac that exceeds the ade resulting in hemodynamic instability necessitates an stretch capacity of the pericardium, generally more than emergency procedure. Blind pericardiocentesis should be 50 to 100 mL.7 performed only in extreme emergency situations. 7 • The space within the pericardial sac is fi nite; however, • Pericardiocentesis is usually performed via a subxiphoid initially large increases in intrapericardial volume result approach. in relatively small changes in intrapericardial pressure. If • Two-dimensional or ultrasound to fl uid continues to accumulate and increases intrapericar- assist in guiding the needle during pericardiocentesis is dial pressures above the fi lling pressures of the right heart, strongly recommended.2,6,7 right–ventricular diastolic fi lling is compromised, result- • This procedure may also be performed with fl uoroscopy ing in cardiac tamponade. 5 in a or interventional radiology • Intrapericardial fl uid accumulation can be acute or chronic suite. and therefore varies in presentation of symptoms. Acute • Urgent or emergent chest exploration is necessary in the effusions are usually a rapid collection of fl uid occurring face of cardiac injury, rapid reaccumulation of pericardial over minutes to hours and may result in hemodynamic fl uid, or ineffective drainage of the pericardium. compromise with volumes of less than 250 mL. 6 Chroni- • There are no absolute contraindications to pericardio- cally developing effusions occurring over days to weeks centesis in the setting of life-threatening hemodynamic allow for hypertrophy and distention of the fi brous instability. Relative contraindications include coagulopa- pericardial membrane. Patients with chronic effusions thy, prior thoracic surgery or pacemaker placement, arti- may accumulate greater than or equal to 2000 mL of fi cial heart valves or other cardiac devices, or inability to fl uid before exhibiting symptoms of hemodynamic directly visualize the effusion using ultrasound during compromise.6 procedure.6 • Symptoms of cardiac tamponade are nonspecifi c so the • Cardiac output is generally improved after diagnosis relies on clinical suspicion and associated signs pericardiocentesis. and symptoms. Acute pericardial effusions are usually a EQUIPMENT This procedure should be performed only by physicians, advanced practice nurses, and other healthcare professionals (including critical care • Pericardiocentesis tray (or thoracentesis tray) nurses) with additional knowledge, skills, and demonstrated competence per • 16-gauge or 18-gauge, 3-inch cardiac needle or professional licensure or institutional standard. over the needle

340 42 Pericardiocentesis (Perform) 341

• Antiseptic skin preparation solution (e.g., 2% is necessary to determine the patient’ s baseline health chlorhexidine-based preparation) status and to identify potential risk factors. The nurse- • Two packs of 4 × 4 gauze sponges patient interaction provides an opportunity for the nurse • No. 11 knife blade with handle (scalpel) to establish a therapeutic relationship focused on the • Sterile 50-mL to 60-mL, 10-mL, 5-mL, and 3-mL syringes patient.2 • Sterile drapes and towels • Assess the patient ’ s neurological status, heart rate, cardiac

• Masks, goggles or face shields, surgical head covers, rhythm, heart sounds (S1 , S 2 , rubs, murmurs), pulmonary sterile gowns, and gloves artery pressures, central venous pressure (noninvasive or • Two three-way stopcocks invasive), blood pressure, mean arterial pressure (MAP),

• 1% lidocaine (injectable) oxygen saturation via pulse oximetry (Sp o 2), and respira- • 10 mL syringe with 25-gauge needle tory status. Rationale: Provides baseline data. • Culture bottles and specimen tubes for fl uid analysis • Evaluate current laboratory values to include a complete • 2-inch and 3-inch tape blood cell count, electrolytes, and coagulation profi le. Additional equipment, to have available as needed, includes Rationale: Review of these data is essential to identify the following: the potential risk of cardiac dysrhythmias or abnormal • Emergency cart (defi brillator, emergency respiratory . If the international normalized ratio or partial equipment, emergency cardiac medications, and tempo- thromboplastin time or both are elevated, reversing the rary pacemaker) level of anticoagulation therapy should be considered • Two-dimensional echocardiography equipment before performing the procedure. It may be prudent to • 12-lead ECG machine defer the procedure until the blood levels indicate a reduc- • Sterile marker tion in bleeding risk.6 • Echocardiogram contrast medium • Suture supplies Patient Preparation • Scissors • Confi rm that the patient and family understand preproce- • If continuous drainage is necessary: dural teaching by having them verbalize understanding. ❖ J guidewire, 0.035 diameter Clarify key points by reinforcing important information ❖ Vessel dilator, 7 Fr and answer all questions. Rationale: Preprocedure com- ❖ Pigtail catheter, 7 Fr munication provides a framework of patient expectations, 2 ❖ Tubing and drainage bag or bottle enhances cooperation, and reduces anxiety. ❖ Three-way stopcock and nonvented caps • Verify that the patient is the correct patient using two identifi ers. Rationale: The nurse should always ensure the PATIENT AND FAMILY EDUCATION correct identifi cation of the patient for the intended inter- vention for patient safety. • Explain to the patient and family the reason necessitating • Obtain informed consent by providing specifi c and rele- the pericardiocentesis (e.g., relief of pressure on the heart); vant information about the procedure. Implied consent describe the procedure in detail, to include risks, benefi ts, may be assumed if emergent life-saving intervention is alternatives, expected outcomes, and potential complica- necessary. Rationale: Informed consent is based on the tions. Rationale: Communication of pertinent information autonomous right of the patient and facilitates a competent helps the patient and family to understand the procedure decision for the patient and the family. 2 and the potential risks and benefi ts, subsequently reducing • Perform a preprocedure verifi cation and time out, if non- anxiety and apprehension.1 emergent. Rationale: Ensures patient safety. • Teach the patient and family about the signs and symp- • Coordinate the procedure with the echocardiogram techni- toms of pericardial effusion (e.g., dyspnea, dull ache or cian or ultrasonographer to assist with the two-dimensional pressure within the chest, dysphagia, cough, tachypnea, echocardiogram or ultrasound if this approach is being hoarseness, hiccups, or nausea).4,5 Rationale: Early rec- used. Rationale: Echocardiogram- or ultrasound-directed ognition of signs and symptoms of recurrent pericardial pericardiocentesis allows for more precise localization of effusion may prompt detection of a potentially life- the effusion and is associated with higher success rates threatening problem. and lower complication rates.5–7 • If nonemergent, prescribe and ensure that an analgesic PATIENT ASSESSMENT AND and/or sedative is administered. Rationale: Analgesia PREPARATION and sedation reduce anxiety and promote comfort and cooperation. Patient Assessment • Apply the limb leads and connect the leads to the cardiac • Elicit the patient ’ s history of the present illness and mech- bedside monitoring system or to the 12-lead ECG anism of injury (if applicable), past medical history, and machine. Rationale: The ECG is monitored during and current medications and/or medical therapies from the after the procedure for changes that may indicate cardiac patient or reliable source. Rationale: A thorough history injury. 342 Unit II Cardiovascular System

Procedure for Performing Pericardiocentesis Steps Rationale Special Considerations 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. Prepare the pericardiocentesis Reduces the potential for . tray and supplies with aseptic technique. 4. Position patient in the supine Facilitates patient comfort, decreases position with the head of the bed work of breathing, and aids elevated 30–45 degrees as the adequate aspiration of fl uid. patient ’ s condition allows. 5. Cleanse the skin with antiseptic Minimizes the potential for infection. Clipping the hair may be necessary solution (e.g., 2% chlorhexidine- before applying antiseptic solution. based preparation) and perform HH. 6. If two-dimensional echocardiogram or ultrasound is being used, skip to step 14. 7. Using maximal barrier Minimizes the risk of infection; precautions, fully drape the maintains aseptic and sterile patient with exposure of only the precautions. surgical site and apply mask, goggles or face shield, surgical cap, sterile gown, and sterile gloves.2 8. Attach a three-way stopcock to a Provides the mechanism to aspirate 3-inch cardiac needle, and attach fl uid. to a 50-mL or 60-mL syringe. 9. If time and patient condition Reduces patient discomfort. Local infi ltration of analgesia reduces permit, inject access site with patient discomfort. 2–3 mL 1% lidocaine using a Alternatively, as the needle is 10-mL syringe and a 25-gauge introduced, the physician, advanced needle, raising a wheal. If unable practice nurse, or other healthcare to perform this step, attach a professional may insert a small syringe with 1% lidocaine to one amount of 1% lidocaine to add side of the stopcock to inject analgesic effect. analgesia during the access procedure. 10. Continuously monitor the bedside Determines patient response during A 12-lead ECG machine can also be

ECG, vital signs, Spo 2 , and the procedure. used for cardiac monitoring. venous pressure during needle aspiration and fl uid withdrawal.2,4,5 42 Pericardiocentesis (Perform) 343

Procedure for Performing Pericardiocentesis—Continued Steps Rationale Special Considerations 11. Subxiphoid approach to Minimizes the risk of cardiac injury; The movement of the heart usually pericardiocentesis ( Fig. 42-1 ): angles > 45 degrees may lacerate the defi brinates blood in the pericardial A. A 16- or 18-gauge needle is liver or stomach. space so that it cannot clot. 8 slowly inserted into the left Clotting usually indicates penetration xiphocostal angle of the heart chamber and blood perpendicular to the skin obtained from within a or 3–4 mm below the left costal . 5 margin. Slowly advance the If clotting occurs with the fl uid needle under the xiphoid obtained, withdraw the needle. toward the left shoulder while If no fl uid is aspirated, withdraw the maintaining negative pressure needle completely and redirect it on the syringe (aspirating). working from the patient ’ s left to B. After the needle is advanced right. to the inner aspect of the rib cage, the needle’ s hub is depressed while the needle points toward the patient’ s left shoulder. The needle is slowly advanced 5–10 mm until fl uid is aspirated. You may feel a distinct “give” when the needle penetrates the pericardium. Successful removal of fl uid confi rms needle position. 12. When the needle position is Removes the pericardial fl uid for Usual tests include body fl uid confi rmed, obtain the fl uid analysis. cytology, cell count, electrolytes, samples and remove the needle. routine aerobic and anaerobic No more than 50–150 mL of cultures, acid-fast bacilli cultures, pericardial fl uid should be and other tests as indicated. removed at one time.5,6 (Level E * ) If continuous drainage is needed, go to step 19. 13. Label the specimen and send the Prepares the sample for analysis. specimen to the laboratory. When Two-Dimensional Echocardiogram or Ultrasound Is Used 14. Perform a two-dimensional Two-dimensional echocardiogram or echocardiogram or ultrasound to ultrasound can help to identify the determine the location and size of location and size of the pericardial the effusion. effusion. 15. Determine the ideal entry site and The ideal entry site is the point where A straight trajectory that best avoids needle trajectory for the the effusion is closest to the vital structures, including the liver, pericardiocentesis. transducer and fl uid accumulation is myocardium, and , should be maximal. 4,6,7 chosen. The internal mammary artery also should be avoided.6–8 16. Mark the skin with a sterile May aid with the procedure. marker. 17. Return to Step 7 and follow the procedural steps.

* Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional orga nizational standards without clinical studies to support recommendations.

Procedure continues on following page 344 Unit II Cardiovascular System

A

D

B E

Figure 42-1 Subxiphoid approach to catheter placement into pericor- dial space. A, A short needle (16 gauge or 18 gauge) is inserted into the left xiphocostal angle perpendicular to the skin and 3 to 4 mm below the left costal margin. B, After the needle is advanced to the inner aspect of the rib cage, the needle ’s hub is depressed so that the needle points toward the patient’ s left shoulder. The needle is then cautiously advanced about 5 to 10 mm until fl uid is reached. The fi ngers may sense a distinct “give” when the needle penetrates the parietal pericardium. Successful removal of fl uid confi rms the needle’ s position. C, The syringe is then disconnected from the needle, and the fl exible tip of the guidewire is advanced into the pericardial space. The needle is withdrawn and replaced with a soft multihole pigtail catheter (6 Fr to 8 Fr) with use of the Seldinger technique. D, After dilation of the needle tract, the catheter is advanced over the guidewire into the pericardial space. E, Once the catheter is properly positioned, aspiration of fl uid should result in rapid improvement in blood pressure and cardiac output, a decrease in atrial and pericardial pressures, and a decrease in the degree of any paradoxical pulse. Electrical alternans, if present, also decreases or disappears. (From C Guidewire Spodick DH: The technique of pericardiocentesis, J Crit Ill 2:91, 1987.) 42 Pericardiocentesis (Perform) 345

Procedure for Performing Pericardiocentesis—Continued Steps Rationale Special Considerations 18. If bloody fl uid is aspirated, a few If the contrast material appears in the Two-dimensional echocardiogram or milliliters of echo contrast pericardial space, the procedure can ultrasound assists in determining medium can be infused to be continued. the position of the needle. confi rm position.6,7 If the contrast material disappears, the Echo contrast is agitated saline A. Echocardiogenic saline can be needle may be in one of the heart solution that is injected via the side prepared by using two 5-mL chambers and must be withdrawn port of the stopcock.6 syringes attached to a three- and repositioned. way stopcock, one fi lled with sterile normal saline and one with air. B. Agitate the saline between the two syringes and inject into the sheath. The agitated saline should appear as an echogenic stream. 7 C. When the fl uid is determined to be pericardial, return to Step 12. When Continuous Drainage Is Desired 19. When the needle tip position is A soft guidewire minimizes the risk confi rmed to be within the of cardiac injury and allows for the pericardial space, insert the passage of the guidewire and fl exible tip of the guidewire placement within the pericardial through the needle into the space. pericardial space and then remove the needle, leaving the guidewire in place. The guidewire is passed so that it wraps around the heart within the pericardial space. 6,7 20. A multiholed pigtail or straight A fl exible-tipped soft catheter with Either a pigtail catheter or a straight soft catheter is passed over the multiple holes in the tip is used to catheter with multiple holes can be guidewire using the Seldinger facilitate drainage of the effusion. used for better drainage. technique 5 (see Fig. 42-1 ). Use of a soft-tipped catheter reduces the chances of causing myocardial injury and dysrhythmias during the procedure.1 21. Remove the guidewire and Maintains asepsis; allows for If the effusion is small, when fl uid is connect the end of the catheter to continual drainage of the effusion. drained remove the catheter. the three-way stopcock and the drainage collection bag.5–7 22. If an indwelling catheter is placed Facilitates fl uid drainage; minimizes to continuously drain a large the potential for infection. pericardial effusion, attach the catheter to the sterile bag or bottle using aseptic technique (see Procedure 78 ). 23. If an indwelling catheter is to Prevents dislodging or accidental remain in place, secure the removal. catheter by suturing the catheter securely to the patient ’ s chest wall. 24. Cleanse the area around the May reduce the risk of infection. catheter with an antiseptic solution and apply an occlusive sterile dressing.3 Procedure continues on following page 346 Unit II Cardiovascular System

Procedure for Performing Pericardiocentesis—Continued Steps Rationale Special Considerations 25. Continue bedside ECG Allows monitoring of cardiac rate and monitoring, and discontinue rhythm. 12-lead ECG if used. 26. Dispose of PE , sharps, and used supplies in appropriate receptacles. 27. HH 28. If an indwelling catheter is May reduce the risk of infection. placed, consider prescribing antibiotics.

Expected Outcomes Unexpected Outcomes • Fluid removed from the pericardial sac • Decrease in blood pressure, increase in venous • Relief of pain, discomfort, or other symptoms that pressure, cardiac dysrhythmias, or excessive bleeding indicated the need for the procedure • Hemodynamic instability • Improved cardiac output • ST-segment depression • Patient ’ s blood pressure, venous pressure, heart • PR-segment elevation sounds, pulse pressure, and cardiac rhythm within • Cardiac tamponade normal limits • Pain

Patient Monitoring and Care Steps Rationale Reportable Conditions These conditions should be reported if they persist despite nursing interventions. 1. Continuously monitor ECG; A change in these signs may indicate • Increasing venous pressure assess (PA) cardiac tamponade, cardiac injury, • Decreasing arterial pressure pressures, venous pressure, blood or hemodynamic instability. • Change in level of consciousness

pressure, Spo 2 , and neurological • Pulsus paradoxus status during and every 15 • Equalizing PA pressures minutes after the procedure until • Decreased cardiac index stable (if available, continuously • Abnormal systemic vascular monitor cardiac index and resistance systemic vascular resistance). 2. Treat dysrhythmias if they occur. Dysrhythmias may lead to cardiac • Persistent dysrhythmias despite decompensation. appropriate intervention 3. Auscultate heart and lung sounds Evaluates potential pericardial fl uid • Asymmetrical breath sounds immediately after the procedure. reaccumulation or puncture of the • Dyspnea lung. • Tachypnea

• Decreased Spo 2 • Distant or faint heart sounds 4. Obtain a portable chest Assesses for and • Pneumothorax radiograph immediately after the hemothorax. • Hemothorax procedure. 5. Obtain a two-dimensional Determines the effectiveness of the • Pericardial effusion echocardiogram within several pericardial drainage. hours after the procedure. 42 Pericardiocentesis (Perform) 347

Patient Monitoring and Care —Continued Steps Rationale Reportable Conditions 6. Monitor the pericardiocentesis Assesses for post-procedural • Bleeding or hematoma at site site for bleeding every 15 hemostasis and possible drainage. minutes after the procedure is completed until the patient ’ s condition is stable, then every 4 hours for 24 hours. If an indwelling catheter is present, continue to monitor the site every 4 hours until the catheter is removed. 7. Monitor hemoglobin, hematocrit, Assesses for potential of effusion • Bleeding or hematoma at site and coagulation studies every 8 recurrence or bleeding at the site. • Decrease in hemoglobin or hours after the procedure for 24 hematocrit values hours or as indicated. • Changes in coagulation study results 8. Assess pericardiocentesis site Determines the presence of infection. • Erythema every day. • Edema • Purulent drainage • Foul odor • Temperature > 100.5°F ( > 38°C) 9. Prescribe site care: A. Cleanse the area surrounding May reduce infection. The Centers for the pericardial catheter with Disease Control and Prevention an antiseptic solution (e.g., (CDC) do not have a specifi c 2% chlorhexidine-based recommendation for care of preparation). pericardial or site care. B. Apply a dry sterile gauze or The CDC recommends replacing transparent dressing with the intravascular catheter dressings date and time of the dressing when the dressing becomes damp, change. loosened, or soiled or when inspection of the site is necessary.3 10. Evaluate the size of the effusion Records how effective drainage was • Increased size of the effusion within 24 hours of the indwelling and whether the need for the catheter placement with the use indwelling catheter continues to of a two-dimensional exist. echocardiogram. 11. Remove the indwelling catheter Minimizes the potential for infection. using aseptic technique when no longer needed. 12. Be prepared for emergent chest Deterioration may indicate • Decreased blood pressure exploration if sudden reaccumulation of cardiac • Presence of dysrhythmias deterioration in the patient ’ s tamponade or cardiac damage. • Increased venous pressure condition occurs. • Change in mental or respiratory status • Diaphoresis • Distant heart sounds 13. Provide emotional support to the Minimizes apprehension and anxiety. patient throughout the procedure. 14. Keep the patient and family The unknown increases the anxiety informed about the patient ’ s and apprehension of the patient and condition. Be available to answer family. patient ’ s and family ’ s questions and facilitate meeting their needs as appropriate. 15. Assess pain and prescribe Identifi es need for pain interventions. • Continued pain despite pain analgesia as needed. interventions Procedure continues on following page 348 Unit II Cardiovascular System

Documentation Documentation should include the following: • Specifi c preprocedure instruction and patient ’ s and • Placement of indwelling catheter (if used) to include family ’ s satisfactory understanding total length, diameter, and length from skin to hub • Universal Protocol requirement, if nonemergent • Removal of indwelling catheter, if used • Legally signed consent form • Assessment of pericardiocentesis fl uid • Pre- and postprocedure level of consciousness; blood • Amount and consistency of postprocedure drainage pressure; venous pressures; pulmonary arterial • Occurrence of unexpected outcomes pressures; cardiac index, cardiac output, systemic • Pain assessment, interventions and effectiveness vascular resistance, if available; heart sounds and • Pre- and postprocedural evaluation and location of cardiac rhythm; respiratory status and pulse oximetry effusion with two-dimensional echocardiogram, if reading used • Pre- and postprocedure hemoglobin, hematocrit, and • ECG rhythm strips coagulation results, if performed • Emergency interventions performed if necessary • Medications administered with dosage and times noted • Specimens sent to the laboratory

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 .