42 Pericardiocentesis (Perform) 341
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PROCEDURE Pericardiocentesis (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 pericardial effusion by fl uid analysis (diagnostic pericardiocentesis) and/or prevention or treatment of cardiac tamponade (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 pericarditis, cancer, 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 heart sounds, and pulsus • Clinical and technical competence in the performance of paradoxus. 4 pericardiocentesis is required. • The amount of fl uid in the pericardium is evaluated • Knowledge of cardiovascular anatomy and physiology is through chest radiograph, two-dimensional echocardio- needed. gram, electrocardiography (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 echocardiography 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 cardiac catheterization 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 catheter 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 , S2 , 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 o2 ), 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 bleeding. 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