Pericardial puncture, pericardiocentesis: methods of performance, complications

Cardiac surgery is a field of medicine that allows regulating the heart's work by means of surgical intervention. It has many different heart surgeries in its arsenal. Some of them are considered quite traumatic and are performed for therapeutic purposes for acute indications. But there are also such types of cardiac surgeries as pericardial puncture, which do not require opening the sternum and penetrating into the heart cavity. This rather informative mini-operation can be performed for both therapeutic and diagnostic purposes. And, despite all the apparent simplicity of execution, it can even save a person's life.

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Indications for the procedure

Pericardiocentesis is an operation that involves removing exudate from the pericardial sac. It is important to understand that some amount of fluid is constantly present in the pericardial cavity, but this is a physiologically determined phenomenon that does not have a negative effect on the heart. Problems arise if more fluid accumulates than usual.

The operation to pump out fluid from the pericardial sac is performed only if preliminary diagnostic studies confirm the presence of effusion in it. The presence of a large amount of exudate can be observed during an inflammatory process in the pericardium (pericarditis), which in turn can be exudative or purulent if a bacterial infection joins in. With such a type of pathology as hemopericardium, a significant number of blood cells are present in the exudate and the pumped out fluid is red.

But pericarditis does not occur on its own either. Effusion into the pericardial cavity can be provoked by both cardiac pathologies, such as myocardial infarction, and diseases not related to the cardiovascular system. Such diseases include: renal failure, rheumatoid arthritis, tuberculosis, collagenosis, uremia. Doctors sometimes observe a similar situation in autoimmune and oncological pathologies. In addition, the presence of purulent exudate in the pericardium can be associated with the presence of a bacterial infection in the patient's body.

Some readers may have a fair question: why pump out fluid from the pericardium if its presence there is considered a physiologically conditioned phenomenon? A small amount of fluid cannot interfere with the work of the heart, but if its volume quickly increases, creating pressure on the vital organ, it becomes more difficult for it to cope with its functions, and cardiac tamponade develops.

Cardiac tamponade is a condition of cardiogenic shock that occurs when the pressure in the pericardial cavity becomes higher than the blood pressure in the right atrium, and during diastole, in the ventricle. The heart is compressed and is unable to provide adequate blood flow. This leads to noticeable circulatory impairment.

If pericardial effusion develops slowly, then a large amount of exudate gradually accumulates in the pericardial sac, which again can provoke cardiac tamponade. In this case, excessive compression of the heart by a large volume of fluid can lead to a critical decrease in blood flow, which requires immediate intervention to save the patient's life.

In all the above cases, pericardial puncture is performed to prevent (planned) or treat (emergency) cardiac tamponade. But this procedure also has a high diagnostic value, so it can be prescribed to identify the nature of the exudate if pericarditis is suspected, which, as we already know, can have various forms.

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Preparation

No matter how easy the procedure for pumping fluid out of the pericardial cavity may seem, it can only be performed after a serious diagnostic examination of the heart, including:

• Physical examination by a cardiologist (study of the patient's medical history and complaints, listening to heart sounds and murmurs, tapping its borders, measuring blood pressure and pulse).
• Taking a blood test that allows you to identify the inflammatory process in the body and determine blood clotting rates.
• Conducting an electrocardiogram. In case of a disturbed pericardial effusion, certain changes will be visible on the electrocardiogram: signs of sinus tachycardia, a change in the height of the R wave, which indicates a displacement of the heart within the pericardial sac, low voltage due to a decrease in electrical current after passing through fluid accumulated in the pericardium or pleura.
• Additionally, central venous pressure can be measured, which is elevated in pericarditis with large effusion.
• Chest X-ray is ordered. The X-ray film will clearly show an enlarged, rounded cardiac silhouette and a dilated caudal vena cava.
• Echocardiography. It is performed the day before surgery and helps to clarify the cause of the disturbed effusion, for example, the presence of a malignant neoplasm or a rupture of the left atrium wall.

Only after the diagnosis of pericarditis is confirmed or an accumulation of exudate in the pericardial cavity is detected, an emergency or planned operation is prescribed to collect fluid from the pericardial sac in order to study it or to relieve the work of the heart. The results of instrumental studies allow the doctor to outline the expected points of pericardial puncture and determine the actual methods of performing the operation.

During the physical examination and communication with the attending physician, it is necessary to tell him about all the medications you are taking, especially those that can reduce blood clotting (acetylsalicylic acid and other anticoagulants, some anti-inflammatory drugs). Usually, doctors prohibit taking such medications for a week before the operation.

In case of diabetes, it is necessary to consult about taking hypoglycemic medications before performing pericardial puncture.

That's about medications, now let's talk about nutrition. The operation should be performed on an empty stomach, so food and even water consumption will have to be limited in advance, which the doctor will warn you about at the stage of preparation for the surgical intervention.

Even before the operation, the medical staff must prepare all the necessary medications used during this procedure:

• antiseptics for treating the skin in the puncture area (iodine, chlorhexidine, alcohol),
• antibiotics for administration into the pericardial cavity after removal of purulent exudate (in case of purulent pericarditis),
• anesthetics for local injection anesthesia (usually lidocaine 1-2% or novocaine 0.5%),
• sedatives for intravenous administration (fentanyl, midazolam, etc.).

Pericardial puncture is performed in a specially equipped room (operating room, manipulation room), which must be supplied with all the necessary instruments and materials:

• A specially prepared table on which you can find all the necessary medications, a scalpel, surgical thread, syringes with needles for administering anesthesia and pericardiocentesis (a 20-cc syringe with a needle 10-15 cm long and about 1.5 mm in diameter).
• Sterile clean consumables: towels, napkins, gauze swabs, gloves, gowns.
• A dilator, sterile clamps, a tube for draining exudate (if there is a large volume of fluid, if it will be drained naturally), a drainage bag with adapters, a large catheter, a guidewire made in the shape of the letter "J".
• Special equipment for monitoring the patient's condition (electrocardiomonitor).

The office must be prepared for emergency resuscitation measures, after all, the operation is performed on the heart and complications are always possible.

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Technique pericardial puncture

After the preparatory part of the procedure is completed, the operation itself begins. The patient is placed on the operating table, semi-lying on his back, i.e. the upper part of his body is raised relative to the plane by 30-35 degrees. This is necessary so that the accumulated fluid during manipulations is in the lower part of the pericardial cavity. Pericardial puncture can also be performed in a sitting position, but this is less convenient.

If the patient is noticeably nervous, he is given sedatives, most often through a venous catheter. The fact is that the operation is performed under local anesthesia, and the person is conscious the entire time, which means he can see what is happening to him and react inadequately.

Next, the skin in the area of the puncture (lower chest and ribs on the left side) is disinfected with an antiseptic. The rest of the body is covered with clean linen. The site of needle insertion (skin and subcutaneous layer) is injected with an anesthetic.

The operation can be performed in several ways. They differ in the place of needle insertion and its movement until it reaches the pericardial wall. For example, according to the Pirogov-Karavaev method, the needle is inserted into the area of the 4th intercostal space on the left side. The pericardial puncture points are located 2 cm to the side of the sternum.

According to the Delorme-Mignon method, the puncture should be located along the left edge of the sternum between the 5th and 6th ribs, and the pericardial puncture points according to the Shaposhnikov method should be located near the right edge of the sternum between the 3rd and 4th ribs.

The most common methods due to their low trauma are the Larrey and Marfan methods. When using them, the risk of damage to the pleura, heart, lungs or stomach is minimal.

Larrey's pericardial puncture involves puncturing the skin near the xiphoid process on the left side where the cartilages of the 7th rib (lower part of the xiphoid process) adjoin it. First, the puncture needle is inserted perpendicular to the body surface by 1.5-2 cm, then it abruptly changes direction and goes parallel to the plane in which the patient lies. After 2-4 cm, it rests against the pericardial wall, the puncture of which is carried out with noticeable effort.

Next, there is a sensation of the needle moving in the void (there is practically no resistance). This means that it has penetrated the pericardial cavity. By pulling the syringe plunger towards you, you can see the fluid entering it. A 10-20 cc syringe is sufficient for diagnostic collection of exudate or pumping out a small amount of fluid.

The puncture must be performed very slowly. The movement of the needle inside the body is accompanied by the introduction of anesthetic every 1-2 mm. When the syringe needle has reached the pericardial cavity, a small dose of anesthetic is additionally injected, after which aspiration (pumping out the exudate) begins.

The needle's movement is monitored using a special electrode attached to it. However, doctors prefer to rely on their own feelings and experience, because the passage of the needle through the pericardial wall does not go unnoticed.

If rhythmic twitching of the syringe is felt, the needle may be resting against the heart. In this case, it is pulled back a little and the syringe is pressed closer to the sternum. After this, you can calmly begin to remove the effusion from the pericardium.

If pericardial puncture is performed for therapeutic purposes when purulent pericarditis is suspected, after the effusion has been pumped out, the pericardial cavity is treated with an antiseptic in a volume not exceeding the amount of exudate pumped out, and then oxygen and an effective antibiotic are introduced into it.

Pericardial puncture at the emergency stage can be performed in conditions where there is a large amount of exudate, posing a danger to the patient's life. One syringe is not enough here. After removing the needle from the body, a guide is left in it, a dilator is inserted into the injection hole and a catheter with clamps is inserted along the guide, to which a drainage system is attached. By means of this design, fluid is subsequently drained from the pericardial cavity.

At the end of the operation, the catheter is firmly attached to the patient's body and left for a certain period of time, during which the patient will be in a medical facility under the supervision of a doctor. If the fluid is pumped out with a syringe, then at the end of the procedure, after removing the needle from the body, the puncture site is briefly pressed and sealed with medical glue.

Marfan's pericardial puncture is performed in a similar manner. Only the pericardiocentesis needle is inserted obliquely under the apex of the xiphoid process and moves towards the posterior sternum. When the needle rests against the pericardial leaflet, the syringe is slightly pulled away from the skin and the organ wall is punctured.

The duration of the procedure for draining fluid from the pericardial sac can vary from 20 minutes to 1 hour. The exudate is pumped out little by little, giving the heart the opportunity to get used to the changes in pressure from the outside and inside. The depth of penetration largely depends on the patient's constitution. For thin people, this figure ranges from 5-7 cm, for overweight people, depending on the thickness of the subcutaneous fat layer, it can reach 9-12 cm.

Contraindications to the procedure

Despite the fact that pericardial puncture is a serious and somewhat dangerous operation, it is performed at any age. The neonatal period is no exception, if there are no other ways to restore coronary blood flow in a baby whose pericardium is accumulating fluid.

There are no age restrictions for the operation. As for health restrictions, there are no absolute contraindications here either. If possible, you should try to avoid such an operation in case of poor blood clotting (coagulopathy), central aortic dissection, low platelet count. However, if there is a risk of serious circulatory disorders, doctors still resort to puncture treatment.

Pericardial puncture is not performed unless the disease is accompanied by a large effusion or rapid filling of the pericardium with secreted exudate. Puncture should also not be performed if there is a high risk of cardiac tamponade after the procedure.

There are certain situations that require special care when performing a puncture. Very carefully remove bacterial exudate from the pericardial cavity in purulent pericarditis, in case of effusion associated with oncological pathologies, in the treatment of hemopericardium developing as a result of injury or trauma to the chest and heart. Complications are possible during surgery and in patients with thrombocytopenia (due to a low concentration of platelets, blood clots poorly, which can lead to bleeding during surgical manipulations), as well as in those who, according to indications, took anticoagulants (drugs that thin the blood and slow its clotting) shortly before the surgery.

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Consequences after the procedure

Pericardial puncture is a cardiac surgical procedure that, like any other heart surgery, has certain risks. Unprofessionalism of the surgeon, ignorance of the surgical intervention technique, violation of the sterility of the instruments used can lead to disruptions in the functioning of not only the heart, but also the lungs, pleura, liver, and stomach.

Since all manipulations are performed using a sharp needle, which can damage nearby organs when moving, it is important not only for the surgeon to be careful, but also to know the paths by which the needle can easily enter the pericardial cavity. After all, the operation is performed almost blindly. The only way to control the situation is to monitor it using ECG and ultrasound machines.

The doctor must try not only to strictly follow the technique, but also to be incredibly careful. Trying to forcefully pass through the pericardial wall, you can overdo it and push the needle into the cardiac membrane, damaging it. This should not be allowed. Having felt the heart pulsation through the twitching of the syringe, you must immediately pull the needle back, letting it go slightly obliquely into the cavity with exudate.

Before the operation, a thorough examination of the heart borders and its work is mandatory. The puncture should be done in the place where there is a large accumulation of exudate; during aspiration, the rest of the intracavitary fluid will be drawn to it.

A responsible approach to choosing a method for puncture of the pericardium is important. Although the Larrey method is preferable in most cases, in some chest deformations, a greatly enlarged liver, encapsulated pericarditis, it is worth considering other methods of performing a pericardial puncture that will not have unpleasant consequences in the form of damage to vital organs by the needle or incomplete removal of exudate.

If the operation is performed in accordance with all requirements by an experienced surgeon, the only consequence of such a procedure will be the normalization of the heart due to a decrease in the pressure of the pericardial fluid on it and the possibility of further effective treatment of the existing pathology.

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Complications after the procedure

In principle, all possible complications that develop in the days following the operation have their origin during the procedure. For example, damage to the cardiac myocardium or large coronary arteries can lead to cardiac arrest, which requires urgent intervention by resuscitators and appropriate treatment in the future.

Most often, the needle damages the right ventricular chamber, which can provoke if not cardiac arrest, then ventricular arrhythmia. Heart rhythm disturbances can also occur during the movement of the conductor, which will be reflected on the cardiac monitor. In this case, doctors are dealing with atrial arrhythmia, which requires immediate stabilization of the condition (for example, the administration of antiarrhythmic drugs).

A sharp needle in careless hands can damage the pleura or lungs along the way, thereby causing pneumothorax. Now fluid accumulation can be observed in the pleural cavity, which will require identical drainage measures (fluid pumping out) in this area.

Sometimes, when pumping out the fluid, its coloring is found to be red. This may be either exudate in hemopericardium or blood as a result of damage to the epicardial vessels by the needle. It is very important to determine the nature of the pumped out fluid as soon as possible. In case of damage to the vessels, the blood in the exudate still quickly coagulates when placed in a clean container, while hemorrhagic exudate loses this ability already in the pericardial cavity.

Other vital organs may also be punctured by the needle: the liver, stomach and some other abdominal organs, which is a very dangerous complication that can lead to internal bleeding or peritonitis, requiring urgent measures to save the patient’s life.

Perhaps not so dangerous, but still an unpleasant consequence after the pericardial puncture procedure is infection of the wound or infection entering the pericardial sac, which leads to the development of inflammatory processes in the body, and sometimes can even cause blood poisoning.

Possible complications can be avoided if you strictly adhere to the puncture treatment (or diagnostic) method, conduct all necessary diagnostic tests, act confidently but carefully, without haste, fuss and sudden movements, and observe the requirements of absolute sterility during the operation.

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Care after the procedure

Even if at first glance it seems that the operation was successful, one cannot exclude the possibility of hidden damage, which will later remind of itself with big troubles, both for the patient and for the doctor who performed the surgical intervention. In order to exclude such situations, and also, if necessary, to provide emergency assistance to the patient in time, an X-ray examination is mandatory after the procedure.

The patient may remain in the medical facility for several days or even weeks after the procedure. If it was a diagnostic procedure that went without complications, the patient may leave the hospital the next day.

In case of complications, as well as when installing a catheter that will drain fluid even after the operation, the patient will be discharged only after his condition has stabilized and the need for drainage has disappeared. And even in this case, experienced doctors prefer to play it safe by additionally conducting an ECG, CT scan or MRI. Conducting tomography is also indicative for identifying neoplasms on the walls of the pericardium and assessing the thickness of its walls.

During recovery after pericardial puncture, the patient is under the supervision of the attending physician and junior medical staff, who regularly measure the pulse, blood pressure, and monitor the patient's breathing characteristics in order to promptly detect possible deviations that were not detected using an X-ray.

And even after the patient leaves the clinic, at the insistence of the attending physician, he will have to adhere to certain preventive measures to prevent complications. This includes revising the diet and nutrition regimen, giving up bad habits, and developing the ability to respond rationally to stressful situations.

If the pericardial puncture is performed for therapeutic purposes, the patient may remain in the clinic until all treatment procedures are completed, which can only be performed in a hospital setting. Performing a mini-operation for diagnostic purposes will give the doctor a direction for further treatment of the patient, which can be performed both in a hospital setting and at home, depending on the diagnosis and the patient's condition.