Table of Contents IntroductionPreparation partPatient partPositioning and exposurePreparationInsertion procedureDrainage optionsRemovalTo complete Before you start Indications: cardiac tamponade (emergency); diagnosis of cause of pericardial effusion; drainage for palliative or prophylactic reasons Contraindications: aortic dissection Relative contraindications: coagulopathy (INR >1.4, platelets <50, therapeutic anticoagulant <24 hours, clopidogrel <7days) Surgical drainage preferred if: traumatic haemopericardium; purulent pericarditis; recurrent malignant effusion; loculated posterior effusion; pericardial biopsy required Guidance: ultrasound guidance is preferred; however, if the patient is critically unwell and ultrasound is unavailable, electrocardiographic monitoring may be used (or procedure may be performed blind in cardiac arrest) Introduction Skip this section if being performed in critically unwell patient Wash hands, Introduce self, Patients name & DOB & wrist band, Explain procedure and get written consentRisks: pain; bleeding; infection; organ puncture & damage (lung, heart, spleen, liver, stomach); pneumothorax; coronary artery injury; internal thoracic artery injury; diaphragmatic injury; cardiac arrhythmias; death**Check patients clotting screen, platelet count and if they have been on an therapeutic anticoagulant/clopidogrel**Perform pre-procedure observations and ensure patient has IV accessEnsure assistant is available and clinical and non-clinical bins are close by to dispose of wasteConfirm pericardial effusion using echocardiography, review images from possible insertion points (see below) and measure the distance of the pericardium from the skin Preparation part Wash hands and apply surgical hat and maskClean a large trolleyGather equipment onto bottom of trolley (think through what you need in order) Equipment list 2x Cleansing snap-sponges (iodine or alcohol/chlorhexidine)Sterile drape with hole in centre (or 2-3 drapes without holes in)10ml syringe and 3 needles (1 blunt fill 18G drawing-up needle, 1 orange 25G, 1 green 21G) for local anaesthetic10ml syringe for aspiration during introducer needle insertion2x 10ml syringes and 1 blunt fill 18G drawing-up needle for agitated saline flush50ml syringe for aspiratingPericardial drain kitScalpel and bladeIntroducer needle with syringeGuidewireDilatorsPericardial drain tube3-way tapDrainage bag with connection tubingAlligator clip electrocardiographic monitoring cableNOTE: if not placing a catheter, you can use a pink 18G spinal needle with large syringe and 3-way tap for multiple aspirationsCotton gauze swabs (used whenever needed throughout procedure to dry/clean sterile area)2-0 silk suture (large hand-held needle) if planning to leave drain in placeSterile dressingSterile ultrasound probe cover and sterile ultrasound gelEquipment to be kept outside of the sterile fieldChlorhexidine hand scrub solutionSterile theatre gownSterile surgical glovesUltrasound scanner with cardiac probe20ml 1% lidocaine (maximum 3mg/kg – note 1ml 1% lidocaine = 10mg)10ml normal salineIf using electrocardiographic monitoring, cardiac monitor Walk to patientWash handsOpen the pericardial drain kit to form a large sterile field on the top of the trolleyOpen packets (without touching the instruments themselves) and drop sterile instruments neatly into the sterile field Pericardiocentesis kit (permission for use granted by Cook Medical, Bloomington, Indiana) Patient part Positioning and exposure Fully expose the anterior patient’s chestPosition patient lying supine on the bed at 30-45˚ with arms rested by sideIdentify insertion point, options:Sub-xiphoid approach: just below xiphoid, slightly to the patient’s left, at 30˚ from horizontal plane, aiming towards left shoulderApical approach: 5th intercostal space, mid-clavicular line, aiming towards right shoulderPara-sternal approach: 5th intercostal space, immediately lateral to left sternal edge with needle perpendicular to skin Preparation Wash hands using Chlorhexidine solution, then apply sterile gown and gloves using the surgical scrub techniqueSterilize areaWork from middle outwards in one spiral motion using cleansing snap-sponge (sterilise the entire anterior chest)Repeat this with 2nd cleansing snap-spongeDiscard used snap-sponges as they are no longer sterile, but note all equipment used after this (including all needles) can be returned to the sterile field after useApply the sterile drape over the patient’s body so that the hole is in the correct place to allow access to the insertion site (or apply 2-3 drapes centred around exposed insertion site if no holes)With the help of the assistant, apply the sterile ultrasound cover and the sterile ultrasound gel and then hold the probe adjacent to the insertion point whenever a needle is being infiltrated to allow real-time ultrasound guidanceAnaesthetise areaAsk assistant to snap open lidocaine bottle and hold open upside-downDraw up lidocaine using drawing-up needle on 10 ml syringe and expel any airChange to the orange needle and insert at an acute angle to form a single subcutaneous bleb around insertion site in order to anaesthetise the skinChange to the green needle and anaesthetise the insertion tractThis is done by instilling lidocaine in small increments of increasing depthAlways aspirate when advancing the needle (so you know if you get to the pericardial cavity) and aspirate before injecting lidocaine (to check you are not in a vessel)Wait 1 minute to work Insertion procedure Make a 5mm skin incision (with the scalpel perpendicular to the skin, press the scalpel blade straight in and out)Introducer needle insertionIf using electrocardiographic monitoring, attach the alligator clip of the electrocardiographic monitoring cable to the distal needle and ask the assistant to attach the other end to a cardiac monitor leadInsert introducer needleSub-xiphoid approach: just below xiphoid, slightly to the patient’s left, at 30˚ from horizontal plane, aiming towards left shoulderApical approach: 5th intercostal space, mid-clavicular line, aiming towards right shoulderPara-sternal approach: 5th intercostal space, immediately lateral to left sternal edge with needle perpendicular to skinNOTE: the needle should be inserted lateral to the ultrasound probe, in the probe’s horizontal plane so the needle can be visualised the entire timeOnce the introducer needle has punctured the skin, remove the stylet (if present) and attach a 10ml syringeSlowly advance the needle through the insertion tract while:Aspirating during infiltration  Watching the ultrasound monitor to guide needleIf using electrocardiographic monitoring, watch the cardiac monitor for ST elevation as the needle makes contact with the right ventricleWhen pericardial fluid is aspirated, stop and remove the syringe from the needlePosition confirmation with agitated saline (if using ultrasound guidance in non-emergency setting)Attach a 3-way tap to the end of the needle, with the needle’s port closed (off switch pointing to that port)Ask assistant to snap open 10ml normal saline bottle and hold open upside-downDraw up 5ml of the saline using a drawing-up needle on 10 ml syringe and expel any air and place in sterile fieldAttach an empty 10ml syringe to a free port of the 3-way tap and move the off switch to close the empty portAspirate 5ml of pericardial fluidNow attach the saline filled syringe to the other empty port and move the 3-way tap off switch to close the pericardial needle’s portHolding the two syringes, expel each in turn repetitively to mix and agitate the saline with the pericardial fluid between the two syringesWhen it makes a foamy colour, draw all of the fluid up in one of the syringesClose the empty syringe’s 3-way tap port and inject the 10ml of agitated saline/pericardial fluid back in to the pericardiumObserve the ultrasound monitor to confirm the air bubbles are contained within the pericardial fluidRemove the 3-way tap 3-way tap Guidewire insertionInsert the guidewire through needle so half the wire is in the chestFrom now on, keep hold of the guidewire at all times with one hand, as close to the skin as possible – you can hold it in a loop to make things easierWithdraw the needle and thread it right the way off the end of the guidewire, ensuring the guidewire remains in placeTract dilationThread the smallest dilator over the guidewire and insert into the chest with a rotational movementWithdraw the dilator and thread it right the way off the end of the guidewire, ensuring the guidewire remains in placeRepeat this with all of the dilators, working your way up the sizesDrain insertionThread the drain over the guidewire until the tip is near the skinNow retract the guidewire slowly until the end comes out of the drainHolding the end of the guidewire, insert the drain into the chestWhen the drain is in place, remove guidewireAttach the 3-way tap with the drain’s port closed (hold finger over end of drain to stop spillage until this is attached)Complete circuitAttach drainage bag tubing to the end port of 3-way tapMove the 3-way tap’s off switch to close the empty middle port to allow free drainage of pericardial fluid into the drainage bag Drainage options Free drainage (leaving drain in situ):Suture the drain in placeApply sterile dressingAllow free drainage for ~30minutes prior to drain removal, or leave in place if likely to re-accumulate Multiple aspirations (then immediate removal):Attach 50ml syringe to middle port of 3-way tap and close the drainage bag’s 3-way tap portAspirate 50ml of pericardial fluidClose the pericardial drain’s 3-way tap port and expel the syringe contents, which will then be diverted into the drainage bagMove the 3-way tap’s off switch back to close the drainage bag’s 3-way tap port and repeat the processKeep repeating the aspiration process above until there is no more fluid to aspirate then remove drain Removal Cut and remove the suture if presentRemove the drainClose the pericardial drain’s 3-way tap portPlace a gauze over the drain site and slowly retract the drainApply a sterile dressing To complete Collect and send samples if requiredThank patient and cover themBin waste and gloves, dispose of sharps safely in sharps bin, clean trolley and wash handsFully document procedure in patients notesEnsure patient is monitored for a few hours and review patient later