Pericardiocentesis

Pediatric Pericardiocentesis

Key Points

Life-saving emergency procedure for cardiac tamponade
Requires immediate recognition and skilled execution
ECG monitoring mandatory during procedure
Success rate highly dependent on operator experience
Echocardiographic guidance significantly improves safety

Definition

Pericardiocentesis is an invasive procedure involving the percutaneous insertion of a needle into the pericardial space to aspirate fluid. In pediatric patients, this procedure requires exceptional precision due to smaller cardiac dimensions and varying anatomical relationships.

Primary Indications

Cardiac tamponade with hemodynamic compromise
Large symptomatic pericardial effusion
Suspected purulent pericarditis
Diagnostic sampling in cases of unknown etiology

Clinical Assessment

Beck's Triad:
- Hypotension
- Distended neck veins
- Muffled heart sounds
Additional Signs:
- Pulsus paradoxus > 10 mmHg
- Tachycardia
- Electrical alternans on ECG
- Enlarged cardiac silhouette on chest X-ray

Pre-procedure Imaging

Echocardiography to confirm:
- Size of effusion
- Location of fluid
- Presence of loculations
- Best approach angle

Absolute Contraindications

Aortic dissection
Uncorrected severe coagulopathy
Inaccessible effusion
Post-cardiac surgery with adherent pericardium

Relative Contraindications

Small, posterior, or loculated effusions
Thrombocytopenia (platelets < 50,000)
Anticoagulation therapy
Previous cardiac surgery
Positive pressure ventilation

Essential Equipment

Emergency Equipment:
- Resuscitation cart
- Defibrillator
- Airway management equipment
Procedure Equipment:
- Sterile gown, gloves, and drapes
- Chlorhexidine or povidone-iodine
- Local anesthetic (1% lidocaine)
- Spinal needles (18-22G)
- Three-way stopcock
- 60mL syringes
- Collection tubes for samples
- ECG monitor
- Echocardiography machine

Procedure Steps

Patient Preparation
- Obtain informed consent
- Position patient supine with 30° head elevation
- Continuous ECG monitoring
- Establish IV access
- Supplemental oxygen
Approach Selection
- Subxiphoid (preferred):
  - Entry at left xiphocostal angle
  - Aim toward left shoulder
  - 30-45° angle to skin
- Alternative approaches:
  - Apical
  - Parasternal
Procedure Execution
- Sterile preparation
- Local anesthetic infiltration
- Advance needle with continuous aspiration
- Monitor ECG for ST changes/arrhythmias
- Confirm position with echocardiography
- Aspirate fluid slowly

Major Complications

Cardiac chamber puncture
Coronary artery laceration
Hemopericardium
Cardiac arrest
Pneumopericardium

Minor Complications

Vasovagal reactions
Arrhythmias
Pneumothorax
Intercostal vessel injury
Local infection

Prevention Strategies

Use of ultrasound guidance
Continuous ECG monitoring
Proper patient positioning
Careful needle advancement

Immediate Post-Procedure Care

Vital signs every 15 minutes for 2 hours
Continuous cardiac monitoring
Post-procedure echocardiogram
Chest X-ray if indicated

Long-term Monitoring

Serial echocardiograms
Monitor for reaccumulation
Follow underlying condition
Plan for definitive treatment

Fluid Analysis

Visual Examination:
- Serous
- Hemorrhagic
- Purulent
Laboratory Tests:
- Cell count and differential
- Protein and LDH
- Glucose
- Gram stain and culture
- Cytology
- PCR for tuberculosis
- Viral studies if indicated

Light's Criteria for Exudates

Fluid/serum protein ratio > 0.5
Fluid/serum LDH ratio > 0.6
Fluid LDH > ⅔ upper limit of normal serum LDH