Wednesday, April 16, 2014

CARDIAC TAMPONADE AND EMERGENCY PERICARDIOCENTESIS


Since moving to New Zealand I have become very impressed by the number of cases of cardiac tamponade that require emergency pericardiocentesis. From malignant effusions, misplaced surgical staples, to post op valve replacements this is a essential life saving skill that all cardiologists here need to develop. I would like to present a case that I was involved in of a middle age man from who presented with breathlessness cardiomegaly, left upper lobe apical mass and a left pleural effusion.

On exam the patient was short of breath had a systolic blood pressure of 90mm with a 15-20mm pulses paradox. The patient had a urgent 2D Echo which demonstrated a large pericardial effusion with collapse of the right ventricle in diastole.  


The patient was taken urgently to the procedure room and elevated to a 30-45 degree angle 2 D Echo of the 5th intercostal space left parasternal view demonstarted a acceptable location for paricardiocentesis. The area was sterilized with antiseptic cleaning fluid and sterile drape applied. After local anesthesia with 2% lidocaine a pericardiocentesis needle was inserted anteriorly into the pericardium after again confirming on ultrasound that this was the optimum location. Bloody fluid was withdrawn while continuously pulling back on the syringe. The syringe was disconnected from the  needle and bloody fluid was dripped on a cloth 4x4 to confirm in did not clot. A soft-tipped guide wire was then inserted and the needle withdrawn. A small incision was made over the entry site and a dilator catheter is inserted to enlarge the track. A multiple side-hole pigtail catheter was then inserted and the guide wire removed. Multiple 20cc syringes were then used to withdraw over a liter of bloody pericardial fluid.
Samples of pericardial fluid were sent for analysis cytology, C&S and biochemistry etc. There was marked improvement in the patients blood pressure and 2D Echo confirmed nearly complete resolution of the pericardial effusion. The pig-tail cannula was sutured in place and connected to a negative pressure vacuum. It is important to leave the drain in until the drainage from the pericardium stops. There is roughly a two liter capacity of the pericardium so until you drain more than two liters of pericardial fluid you should not be concerned about further accumulation of pericardial fluid. When the pericardium is dry the patient will start to develop discomfort from the pericardial drainage tube.
The patient became completely asymptomatic and was able to walk out of the hospital 3 days later.
Cytology of the pericardial fluid unfortunatley returned positive for adenocarcinoma. We all felt we had saved this man by our prompt actions and had given him a few more weeks or months of quality time with his family. Kia Ora from New Zealand!
PS: Don't try to drain traumatic pericardial effusions without a Heart Surgeon being present!









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