Pericardiocentesis 

1️⃣ Basic Anatomy & Physiology

Pericardium

The pericardium has two layers:

• Fibrous pericardium – tough outer layer
• Serous pericardium
• Parietal layer
• Visceral layer (epicardium)

Normal pericardial fluid: 15–50 mL

3️⃣ Indications of Pericardiocentesis

🔴 Emergency (Absolute)

• Cardiac tamponade with hemodynamic instability
• PEA arrest with suspected tamponade

🟡 Urgent / Diagnostic

• Large symptomatic effusion
• Suspected bacterial / TB / malignant effusion
• Recurrent effusion

4️⃣ Contraindications

Absolute

• Aortic dissection (risk of worsening bleed)

Relative

• Uncorrected coagulopathy
• Severe thrombocytopenia
• Small posterior loculated effusion

⚠ In unstable tamponade → NO absolute contraindication

5️⃣ Pre-Procedure Evaluation

A. Echocardiography (Gold Standard)

Echo signs of tamponade:

• RA systolic collapse
• RV diastolic collapse
• IVC plethora
• Swinging heart
• Respiratory variation in mitral/tricuspid inflow

B. ECG Findings

• Low voltage QRS
• Electrical alternans

C. Labs

• CBC
• INR/PTT
• Platelets
• Crossmatch (if hemopericardium suspected)

6️⃣ Approaches to Pericardiocentesis

1️⃣ Subxiphoid (Most Common Traditional)

• Needle inserted 1–2 cm below xiphoid
• Directed toward left shoulder
• 30–45° angle

Advantages:

• Avoids pleura
• Safer in emergency

2️⃣ Parasternal Approach

• 5th–6th intercostal space
• Just left of sternum
• Avoid internal mammary artery

3️⃣ Apical Approach (Echo-Guided Preferred)

• Near cardiac apex
• Shortest distance to fluid

🔹 Current standard: Ultrasound-guided approach (AHA / ESC recommended)

7️⃣ Procedure – Step-by-Step (ICU Practical)

Preparation

• Informed consent (if possible)
• Resuscitation equipment ready
• Defibrillator attached
• Continuous ECG monitoring

Position

• Semi-recumbent (30°)

Technique (Seldinger Method – Preferred)

1. Local anesthesia (lidocaine)
2. Insert 18 G needle under echo guidance
3. Aspirate fluid
4. Insert guidewire
5. Dilator
6. Pigtail catheter placement
7. Connect to drainage bag

• Always aspirate slowly
• Do not remove >1 L rapidly
• Leave catheter until <25–50 mL/day drainage

Confirm Placement

• Echo visualization
• Agitated saline injection (bubble study)
• ECG changes if myocardial contact

8️⃣ Fluid Analysis 

Send for:

• Cell count
• Protein
• LDH
• Glucose
• ADA (TB suspicion)
• Gram stain
• Culture
• Cytology
• AFB stain
• PCR (if indicated)

Causes of Pericardial Effusion 

9️⃣ Complications

Immediate

• Arrhythmias (PVCs, VT)
• Coronary artery injury
• Myocardial puncture
• Pneumothorax
• Liver injury (subxiphoid)

Delayed

• Re-accumulation
• Infection
• Constrictive pericarditis

🔟 Pericardiocentesis vs Pericardial Window

1️⃣1️⃣ Special Situations

Trauma

• FAST positive + shock → immediate drainage

Aortic Dissection

• Avoid unless cardiac arrest (controversial)

Uremic Effusion

• Dialysis first unless tamponade

Post-Cardiac Surgery

• Often loculated → surgical drainage preferred

1️⃣2️⃣ Hemodynamic Effect After Drainage

• Sudden ↑ venous return
• Improved BP
• Decreased JVP
• Improved urine output

⚠ Rare complication: Pericardial decompression syndrome

• Acute LV failure
• Pulmonary edema

1️⃣3️⃣ Pericardial Decompression Syndrome

Mechanism:

• Sudden increase in venous return
• LV cannot adapt
• Acute pulmonary edema

Management:

• Supportive
• Diuretics
• Ventilation

1️⃣4️⃣ Exam-Trap Points

✔ Pulsus paradoxus absent in:

• Severe AR
• ASD
• Mechanical ventilation

✔ Electrical alternans = large effusion, not always tamponade

✔ RA collapse > 1/3 cardiac cycle = tamponade sign

✔ Tamponade is clinical diagnosis – echo supports