Cardiac tamponade and Pericardiocentesis Made Easy www.cardiconcept.com
Etiology of pericardial diseases. Non Infectious cause Infectious cause European Heart Journal (2015) 36, 2921 2964
Recommendations for the diagnosis of pericardial effusion Echocardiography (I) Chest X-ray (I) CRP (I) CT or CMR for loculated pericardial effusion (IIa) European Heart Journal (2015) 36, 2921 2964
A simplified algorithm for pericardial effusion triage and management. e.g. if known Hypothyroid, renal disease, heart failure, autoimmune Rx the disease Pericardiocenthesis 1) Tamponade 2) suspected malignancy or infection 3) Large Chronic pericardial effusion > 3 months European Heart Journal (2015) 36, 2921 2964
Cause of cardiac tamponade European Heart Journal (2015) 36, 2921 2964
Parrillo, Joseph E.; Dellinger, R. Phillip. Critical Care Medicine: Principles of Diagnosis and Beck s triads JVP BP Muffle heart sound or Distant heart sound
Recommendations for the diagnosis and treatment of cardiac tamponade Echocardiography 1 st line imaging (I) Urgent pericardiocentesis (I) ใช Echocardiography for guide the timeing of pericardiocentesis(i) Vasodilator and diuretics (III) European Heart Journal (2015) 36, 2921 2964
Pulsus paradoxus 10 mmhg
Echocardiography or Ultrasound
Indication For Diagnostic For Therapeutic Asymptomatic patients with large effusions do not require pericardiocentesis Unless hemodynamic compromise or for diagnostic Cardiac tamponade Emergency pericardiocentesis Parrillo, Joseph E.; Dellinger, R. Phillip. Critical Care Medicine: Principles of Diagnosis and
Parrillo, Joseph E.; Dellinger, R. Phillip. Critical Care Medicine: Principles of Diagnosis and Objective (1) relief of tamponade (2) obtaining fluid for appropriate analyses (3) assessment of hemodynamics after pericardial fluid evacuation to exclude effusive-constrictive pericardial effusion.
Contraindication Elective pericardiocentesis and receiving anticoagulation bleeding disorders or thrombocytopenia (platelet count < 50,000/ µl). Small pericardial effusion or loculated Complicating acute dissecting aorta Parrillo, Joseph E.; Dellinger, R. Phillip. Critical Care Medicine: Principles of Diagnosis and
Parrillo, Joseph E.; Dellinger, R. Phillip. Critical Care Medicine: Principles of Diagnosis and Technique administration of local anesthesia (1% to 2% lidocaine) to the skin and deeper tissues of the left xiphocostal area
Parrillo, Joseph E.; Dellinger, R. Phillip. Critical Care Medicine: Principles of Diagnosis and Technique Ultrasound guided pericardiocentesis
Technique Electrocardiographic monitoring If ST segment elevation withdraw needle slightly the pericardial needle is connected to an ECG lead. (Not chest wall)
Parrillo, Joseph E.; Dellinger, R. Phillip. Critical Care Medicine: Principles of Diagnosis and Technique Blind approach (Not recommend) Only if both Ultrasound or ECG guided are not available aiming toward the left shoulder
Parrillo, Joseph E.; Dellinger, R. Phillip. Critical Care Medicine: Principles of Diagnosis and Technique Draw negative
Parrillo, Joseph E.; Dellinger, R. Phillip. Critical Care Medicine: Principles of Diagnosis and Technique a guidewire is introduced in the pericardial space through the needle.
Parrillo, Joseph E.; Dellinger, R. Phillip. Critical Care Medicine: Principles of Diagnosis and Technique A small skin incision with a #11 scalpel facilitates passage of the dilator and subsequently the drain The dilator is slowly advanced over the guidewire just enough to enter the pericardial cavity. Following dilation, the dilator is removed.
Technique the percutaneous drain is advanced over the guidewire until the holes are all in the pericardial cavity.
Parrillo, Joseph E.; Dellinger, R. Phillip. Critical Care Medicine: Principles of Diagnosis and Technique Connect with radivac drain
Complication Laceration of heart and coronary vessel Puncture of RA or RV air embolism Arrhythmia Pneumothorax Puncture in peritoneal cavity or visceral organ Parrillo, Joseph E.; Dellinger, R. Phillip. Critical Care Medicine: Principles of Diagnosis and
Acute LV failure after large volume pericardiocentesis Rare,but serious Mechanism?? Interventricular volume mismatch Sudden increase RV volume Increase wall stress (Laplace law : Increase diameter increase wall stress) high filling pressures, combined with a vacuum effect of the evacuated pericardial space.
Parrillo, Joseph E.; Dellinger, R. Phillip. Critical Care Medicine: Principles of Diagnosis and Other approach parasternal approaches. Puncture of the left pleura and the lingula is more frequent Apical Puncture of the left anterior descending and the internal mammary artery right xiphocostal higher incidence of right atrium and inferior vena cava injury.
Management After Pericardiocentesis Pericardiocentesis does not completely evacuate the effusion in most cases. Leave the catheter in place for 24 to 72 hr. the pericardial catheter is removed usually within 72 hours, and decisions for additional therapy are contemplated. If drain >100 ml of fluid/ 24 hours X 3 days considered for more aggressive therapy. (common in malignant pericardial effusion) Parrillo, Joseph E.; Dellinger, R. Phillip. Critical Care Medicine: Principles of Diagnosis and
Management After Pericardiocentesis Uncomplicated pericardiocentesis No special care is required If tamponade watch for signs of recurrent tamponade. follow-up echocardiogram is useful Parrillo, Joseph E.; Dellinger, R. Phillip. Critical Care Medicine: Principles of Diagnosis and
Parrillo, Joseph E.; Dellinger, R. Phillip. Critical Care Medicine: Principles of Diagnosis and indication for an open surgical pericardial window or for percutaneous balloon pericardiotomy. Reaccumulation of fluid with recurrence of cardiac tamponade
Open surgical pericardial window Safe Under local anesthesia Symptomatic recurrence rate 5% Parrillo, Joseph E.; Dellinger, R. Phillip. Critical Care Medicine: Principles of Diagnosis and
Parrillo, Joseph E.; Dellinger, R. Phillip. Critical Care Medicine: Principles of Diagnosis and Percutaneous balloon pericardiotomy Injection of a small amount of iodinated contrast an inflated dilating balloon catheter without a waist, indicating the need to reposition the balloon catheter The balloon catheter is in the correct position
Complication of balloon pericardiotomy 13% of patients Pleural effusion within 24-48 hr after procedure (resolve spontaneously) not advised to perform the procedure in patients with marginal pulmonary reserve. Bleeding complication Parrillo, Joseph E.; Dellinger, R. Phillip. Critical Care Medicine: Principles of Diagnosis and
Analysis of Pericardial Fluid Small yield in identifying the etiology European Heart Journal (2015) 36, 2921 2964
A step-wise protocol for the evaluation of suspected tuberculous pericarditis and pericardial effusion Step 1 : Initial non-invasive evaluation e.g. CXR, echocardiography Sputum, lymphnode biopsy, TFT, creatinine, ANA,RF etc. Step 2 : Pericardiocentesis Step 3 : Pericardial biopsy Step 4 : Empirical therapy for tuberculosis 2IRZE / 4IR Steriod (optional) European Heart Journal (2015) 36, 2921 2964
Recommendations for the diagnosis and treatment of Tuberculous pericarditis and effusion Pericardiocentesis (IIa) Empirical anti-tuberculosis in endemic area (I) Steroid in HIV-negative case (IIb) European Heart Journal (2015) 36, 2921 2964
Reference Parrillo, Joseph E.; Dellinger, R. Phillip. Critical Care Medicine: Principles of Diagnosis and Management in the Adult. Elsevier Health Sciences. Hanna MD, Elias B.; D. Luke MD Glancy. Practical Cardiovascular Hemodynamics. Springer Publishing.
Reference