Pericardiocentesis in Pediatrics

Topic Name Introduction Indications & Assessment Contraindications Equipment & Preparation Procedure Technique Complications Post-Procedure Care Fluid Analysis

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

1. Patient Preparation
   • Obtain informed consent
   • Position patient supine with 30° head elevation
   • Continuous ECG monitoring
   • Establish IV access
   • Supplemental oxygen
2. Approach Selection
   • Subxiphoid (preferred):
     • Entry at left xiphocostal angle
     • Aim toward left shoulder
     • 30-45° angle to skin
   • Alternative approaches:
     • Apical
     • Parasternal
3. 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