Pericardiocentesis and Drainage by a Silicon Rubber Line. without Echocardiographic Guidance. Experience in 55 Consecutive Patients

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1 Pericardiocentesis and Drainage by a Silicon Rubber Line without Echocardiographic Guidance Experience in 55 Consecutive Patients Kunshen LIU, M.D., Wenling LIU, M.D., Xiaotao LI, M.D., Yue XIA, M.D., Guohua WAN, M.D., Sujie YANG, M.D., Shuping MA, M.D., Xizheng HUANG, M.D., Xiaoyong QI, M.D., and Jinquan LIANG, M.D. SUMMARY Pericardiocentesis and drainage with a silicon rubber line were performed safely in 55 patients via the subxiphoid (80 times) or apical (1 time) approach at the bedside without echocardiographic guidance. The subxiphoid approach, which is close to the posterior of the sternum or the costal cartilage with a small acute-angle (15-30 ) to the parietal pericardium in front of the right ventricle, can avoid injuring the heart, liver and lungs. A line with sideholes near the distal end, which provides convenient drainage and has better histocompatibility, can be kept in place for a long period of time (1-82 days). It was also convenient to inject air, drugs or fluid through the line. There were no procedure-related serious complications or deaths. Emergency drainage with the Seldinger technique, especially for small to moderate effusions, is safe and simple. (Jpn Heart J 35: , 1994) Key words: Pericardial effusion Pericardiocentesis Drainage Silicon rubber line Seldinger technique NTIL recently, pericardiocentesis was associated with a significant incidence of serious complications, including laceration of the heart or coronary vessels, arrhythmias, pneumothorax, trauma to abdominal organs and death,1) particularly in the case of a small but acute effusion. The advent of 2- dimensional echocardiography (2-D echo) has made the procedure safer than before. Percutaneous pericardiocentesis guided by 2-D echo combined with drainage by an indwelling pericardial catheter was reported to be a safe alterna- From Cardiovascular Division, Department of Medicine, Hebei Provincial Hospital, Shijiazhuang City, Hebei Province, China. Address for correspondence: Kunshen Liu, M.D., Cardiovascular Division, Department of Medicine, Hebei Provincial Hospital, Shijiazhuang City, Hebei Province, China Received for publication June 16, Accepted September 21,

2 752 LIU ET AL Jpn Heart J November 1994 tive with a low incidence of complications and no procedure related deaths.1,2) However, sophisticated techniques are too difficult to employ for the emergency treatment of pericardial tamponade. A simple and safe technique of tap and drainage with a silicon rubber line at bedside without 2-D echo guidance has been developed at our institute. It was particularly successful in tapping and draining small effusions by the Seldinger technique. MATERIALS AND METHODS Patients: From January 1987 to June 1994, 55 consecutive patients underwent taps and drainage with a line inserted via the subxiphoid (80 times) or apical (1 time) approach at bedside without 2-D echo guidance. The indications for tap and drainage were large, acute and life-threatening pericardial effusions. 33 patients (50 instances, 62%) suffered from large effusions severely compromising hemodynamic and clinical stability; 14 patients (18 instances, 22%) had large effusions; 8 patients (13 instances, 16%) had small to moderate effusions requiring emergency tap and drainage. The effusions were classified as large, moderate and small according to the thickness of the echoless-zone thickness around the heart, especially the thickness in front of or under the right ventricle (more than 15mm large, 10-15mm moderate and less than 10mm small). Effusions of 5-15mm were considered suitable for drainage by the Seldinger technique. All patients or their relatives gave informed consent before the procedures. Materials: Silicon rubber line, 25cm long, outer diameter 1.8mm, inner diameter 0.8mm, the distal end was bevelled and 8-10 sideholes were made within 4-5cm near the end; connecting tube, 25cm long, the distal end to connect to the line, the proximal end (drainage hole) to connect to the syringe; No.18, No. 16 (or finer) puncture needle; No.11 scalpel; plug for occluding the drainage hole; 6F dilator and sheath; J-tipped guide-wire; 20cm stylet; 50ml syringe (Figure 1). Method: The pericardial effusion must be confirmed under 2-D echo by the responsible physician himself before the procedure. It is preferable to use a finer puncture needle (No.16 or finer) with the Seldinger technique in the case of a small to moderate effusion, especially one of 5-10mm thickness (small effusion). However, most patients, with a large effusion were suitable for the insertion of the line directly through a No.18 puncture needle. Direct method: The patient is placed in the Fowler position (45 angle to the bedplane). The junction of the xiphoid process and the left costal arch, costoxiphoid angle, must be identified by palpation before the procedure. The field is cleaned and toweled, local anaesthetics injected at a site 1-2cm beneath the angle, and a small nick is made with a No.11 scalpel. The No.18 needle with

3 Vol 35 No 6 PERICARDIOCENTESIS AND DRAINAGE BY A SILICON RUBBER LINE 753 Figure 1. Equipment. 1. No.18 puncture needle, 2. Drainage line, 3. Stylet, 4. Connecting tube, 5. Plug, 6. Dilator and sheath with Seldinger technique, 7. J-tripped guide wire. Figure 2. Illustration of the tap and drainage; the approach is similar to a parallel stick in venous puncture. 1. Pericardial effusion, 2. Pericardium, 3. Xiphoid process, 4. No.18 puncture needle, 5. Silicon rubber line syringe filled with anesthetics sticks in the nick and engages the periosteum under the angle, then the needle point is withdrawn a little, depressed a little and advanced. This is repeated a few times until it passes through close to the posterior of the sternum or costal cartilage. The puncture direction is about a angle to the frontal plane towards the left supraspinous fossa or a site suitable to puncture predetermined by 2-D echo (Figure 2). The needle is carefully advanced little by little with negative pressure, a small volume of anesthetic being injected when the needle is advanced so that the small tissue strip in the needle can be pushed out. The needle is stopped as soon as the effusion appears in the

4 754 LIU ET AL Jpn Heart J November 1994 syringe. The syringe is withdrawn and the line is inserted 20cm or more through the needle. If resistance is met during insertion, the needle is turned or advanced slightly or the line is threaded with a stylet and then advanced until it enters the pericardial cavity. Seldinger technique: The puncture steps as mentioned above are performed with a No.16 (or finer) needle until the effusion gushes into the syringe. First, a sample of the effusion is taken because the Scldinger technique can stain the effusion. The J end of the guide-wire is then inserted into the pericardial cavity 20cm or more, the access dilated with a thicker dilator, and the dilator replaced by a 6F dilator and sheath until resistance disappears and the sheath enters the pericardial sac. The 6F dilator and guide-wire are withdrawn, the line is inserted into the pericardial sac 20cm or more through the sheath and the sheath is taken off while the line is maintained in place. The line with the nick is then fixed by suture and connected by a connecting tube. The effusion is gradually drained ( ml each day, or more if the effusion is hypertensive) until the effusion disappears or little effusion can be drained. The drainage hole is plugged after the procedure. RESULTS The direct method was performed successfully in 40 patients with large effusions, which were drained 61 times. The Seldinger technique was performed successfully a total of 20 times in 15 patients with cardiac tamponade; 6 patients had small effusions, 2 had moderate effusions and 7 had large effusions. All patients were drained by the subxiphoid approach, except for one, whose effusion was mainly present in the posterior pericardial space. That patient was drained via the apical approach with the Seldinger technique. Air was injected in 50 patients to observe pericardial disorders; normal saline was instilled to wash out the effusions in 30 patients; drugs were instilled in 48 patients to treat various disorders. There were no procedure-related severe complications; small hematomas and local pain around the nick developed in 3 patients due to hypertensive effusions. These disappeared after additional drainage. Mild pain in the left chest, possibly due to effusion leakage into the thorax cavity, was found in the patient drained by the apical approach. The line remained for 1-82 days (median 10 days) and drained ,000ml (median 1600ml). There were 3 patients referred to surgery for constrictive pericarditis, 23 patients were cured clinically, and 29 patients whose condition was alleviated before discharge. No procedure resulted in death.

5 Vol 35 No 6 PERICARDIOCENTESIS AND DRAINAGE BY A SILICON RUBBER LINE 755 DISCUSSION The subxiphoid approach is close to the posterior of the sternum or costal cartilage, with a small acute-angle to the parietal pericardium in front of the right ventricle, and is similar to the parallel puncture technique for venous puncture. Therefore, even a small effusion can be tapped at the bedside with the Seldinger technique using a finer needle without 2-D echo guidance. In this way injury to the heart, liver and lungs can be avoided. The Seldinger technique is even safer than the direct method, especially for small effusions. Although most of the pericardial effusions are present in the posterior pericardial space, an effusion in front of and under the right ventricle always appears, particularly with the patient in the sitting or Fowler position. In addition, the subxiphoid approach does not pass through the abdominal and thoracic cavities. Therefore, we prefer this approach. The acute small effusion, which mainly appears in the posterior pericardial space, and cannot be tapped by the subxiphoid approach, can be drained by the apical approach with the Seldinger technique. The guide-wire can be inserted directly into the posterior pericardial space when the needle is directed posteriorly. Therefore, the Seldinger technique in the apical approach may be useful for the drainage of small posterior effusions. However, small effusion leakage into the thoracic cavity might appear, it is less dangerous than cardiac tamponade. The line with multiple sideholes is convenient for drainage, the distal bevelled end is easy to insert, and the silicon rubber has better histocompatibility than a plastic cannula or pigtail catheter. Therefore, there were few reactions around the nick and patients could tolerate long-term drainage. Noteworthy was the fact that although the method can be used without 2- D echo guidance at bedside, the effusion must be checked before the procedure. It is not reliable to tap according to the signs and symptoms of cardiac tamponade. For example, one time, pericardial tamponade with a tumor mass was suspected as a large effusion occurred soon after the drainage line was withdrawn. A tap was performed immediately without 2-D echo and the needle entered the cardiac cavity through the tumor, luckily without severe complication. A line plugged with protein clots, which is common and troublesome with pigtail catheter drainage1), developed in 3 patients and was resolved easily by kneading the lines. We believe that this technique is simple, safe and easy to learn. It can be done at the bedside without 2-D echo guidance, and is especially useful to drain small effusions in emergency pericardial tamponade with the Seldinger technique.

6 756 LIU ET AL Jpn Heart J November 1994 REFERENCES 1. Kopeky SL, Callahan JA, Tajik AJ, Seward JB: Percutaneous pericardial catheter drainage; report of 42 consecutive cases. Am J Cardiol 58: 633, Callahan JA, Seward JB, Nishimura RA, Miller FA, Reeder GS, Shub C, Callahan MJ, Schattenburg TT, Tajik AJ: Two-dimensional echocardiographically guided pericardiocentesis; Experience in 117 consecutive patients. Am J Cardiol 55: 476, 1985