Pericardiocentesis technique

This has appeared in a few past questions; specifically, Question 5 from the second paper of 2016 and the identical Question 15 from the first paper of 2011 ask you to describe "how you would perform blind pericardiocentesis."

Only 25% of candidates passed that question. This is consistent with the expected level of experience of this procedure. Judging by a brief Google search, much of the modern literature on this topic is concerned with harping on about how great it is that this dangerous procedure is dying out, being replaced by safer ultrasound-guided methods.

The approach is as follows:

  • Raise the head of the bed 45° if the situation permits
  • Antibacterial prep and drape
  • Palpate the xiphisternum and ribs: that is your landmark.
  • There are three main approaches:
    • Subxiphoid approach: Insert needle just under the xiphoid, and advance in the direction of the left shoulder while aspirating.
    • Parasternal approach: Insert the needle perpendicular to the chest wall in the fifth intercostal space, just lateral to the sternum.
    • Apical approach: insert the needle in the intercostal space below and 1 cm lateral to the apex beat, aimed toward the right shoulder.
  • Withdraw fluid until cardiac output improves
  • Advance guidewire and dilate over it.
  • Advance pigtail catheter over guidewire, and suture in place

The college answer also suggests one connect  an ECG lead (one of the chest leads) to the base of the needle  and watch the ECG to look for a change  in  the  QRS  morphology,   or  ST  elevation  if  the  needle  contacts  the myocardium.

Complications of pericardiocentesis include:

  • myocardial perforation
  • bleeding
  • pneumothorax
  • arrhythmia
  • acute pulmonary edema (due to rapid drainage of periciardial fluid leading to excessive LV preload)
  • acute ventricular dilatation