Pericardiocentesis (pediatrics)

Indications and technique

 * pericardial puncture is performed for diagnostic or therapeutic reasons;
 * the safest way to perform pericardial puncture is under echocardiographic control;
 * If echo is not available, the use of the precordial ECG lead attached to the puncture needle may reduce the risk of complications (ST or PR segment elevation indicates needle contact with the ventricular or atrial pericardium);
 * adequate analgesic sedation is necessary;
 * place the patient in a supine position with the upper body increased by 30 degrees;
 * during the procedure we monitor the ECG and, if possible, other hemodynamic parameters (arterial blood pressure, CVP);
 * disinfect the skin area at the lower edge of the sternum and perform local anesthesia with 1 % mesocaine;
 * the injection site is just below the xiphoides process, or 1 cm to the left of the midline below the xiphoides process;
 * use an intravenous cannula size G 18 až 14, to which we connect a 10 ml syringe;
 * insert the cannula through the chest wall slowly, creating a vacuum toward the left shoulder, at an angle of 30 degrees to the anterior chest wall;
 * as soon as we start aspirating the pericardial effusion, we just insert the cannula and pull out the needle;
 * if we suck blood, the following will be used to distinguish hemorrhagic effusion from blood from the heart:
 * observing clotting (blood clots from the heart) ;
 * dripping a drop of aspirate on white swab: if a central red color develops and pale court on the periphery, it is a bloody effusion if it is red;

without a backyard, it is blood from the heart cavity;
 * hematocrit examination provides exact verification;


 * to determine the position of the cannula, 2 to 3 ml of saline can be injected through the cannula: depending on the position of the cannula, the microbubble is displayed in the pericardial cavity or in the right ventricle in the ultrasound image;
 * in patients with large, chronic effusion who have failed medication or who require repeated pericardiocentesis, we can ensure continuous drainage of the effusion by inserting a J-shaped soft catheter (pigtail catheter) into the pericardial cavity by Seldinger technique (the catheter can be left in the pericardial cavity 2 to 7 days).

Complications

 * arrhytmia
 * myocardial laceraton
 * coronary artery disease
 * PNO

Examination of pericardial effusion
The effusion is sent for cytological, biochemical, microscopic (Gram staining) and culture examinations.

Normal pericardial fluid is clear or light yellow. In bacterial pericarditis, the exudate is slightly turbid, rarely purulent. Bloody or serosangvinous effusion is a non-specific finding, occurring in infections, tumors, collagenoses, injuries and postpericardiotomy syndrome.

Leukocyte counts > 1 000/ml with a predominance of polymorphonuclear leukocytes are determined in infectious pericarditis, lymphocyte predominance in TBC pericarditis, tumor cells in neoplasms, LE-cells in SLE.

The level of glucosis is lower in infectious pericarditis and can be reduced in neoplasia and febris rheumatica. With SLE, glucose is normal.

LDH levels are elevated in neoplasms.

The level of fibrinogen in exudates is higher than in transudates (in exudates > 5 %).

Related articles

 * Pericardiocentesis
 * Heart
 * Heart/histologiy
 * Pericardium
 * Cardiac conduction system
 * Vascular supply of the heart
 * X-ray image of the heart
 * Congenital heart defects
 * Cor pulmonale

Source

 * HAVRÁNEK, Jiří: Perikardiální punkce. (upraveno)