What is the ideal approach for emergent pericardiocentesis using point-of-care ultrasound guidance?

Abstract

BACKGROUND: Traditionally performed using a subxiphoid approach, the increasing use of pointof-care ultrasound in the emergency department has made other approaches (parasternal and apical) for pericardiocentesis viable. The aim of this study is to identify the ideal approach for emergency-physicianperformed ultrasound-guided pericardiocentesis as determined by ultrasound image quality, distance from surface to pericardial fl uid, and likely obstructions or complications. METHODS:A retrospective review of point-of-care cardiac ultrasound examinations was performed in two urban academic emergency departments for the presence of pericardial eff usions. The images were reviewed for technical quality, distance of eff usion from skin surface, and predicted complications.RESULTS: A total of 166 pericardial effusions were identified during the study period. The mean skin-to-pericardial fl uid distance was 5.6 cm (95% confi dence interval [95% CI] 5.2-6.0 cm) for the subxiphoid views, which was signifi cantly greater than that for the parasternal (2.7 cm [95% CI 2.5-2.8 cm], P<0.001) and apical (2.5 cm [95% CI 2.3-2.7 cm], P<0.001) views. The subxiphoid view had the highest predicted complication rate at 79.7% (95% CI 71.5%-86.4%), which was signifi cantly greater than the apical (31.9%; 95% CI 21.4%-44.0%, P<0.001) and parasternal (20.2%; 95% CI 12.8%-29.5%, P<0.001) views. CONCLUSIONS:Our results suggest that complication rates with pericardiocentesis will be lower via the parasternal or apical approach compared to the subxiphoid approach. The distance from skin to fl uid collection is the least in both of these views.

A novel in-plane technique ultrasound-guided pericardiocentesis via subcostal approach

“…When choosing the site of the emergency pericardiocentesis, the ideal approach for using point-of-care ultrasound guidance should take into consideration the distance of effusion to the probe, image quality, and predicted complications. Stolz et al predicted that the subcostal approach had the highest complication rate compare to other methods [ 12 ]. This was because of its long distance from the skin to the pericardial space, which increased the risk of injury to the liver, blood vessels and bowels.…”

Removing pericardial drainage tube for acute cardiac tamponade associated with catheter ablation of atrial fibrillation can trigger hemoperitoneum from severe liver bleeding

“…The subxiphoid approach has the longest distance from the skin to the pericardial fluid. 8 In contrast, the increasing use of the TTE has enabled the other 2 methods to be safer than the subxiphoid approach. In fact, previous studies have suggested that the parasternal approach is safest if guided by a TTE.…”

Non-traumatic parasternal pericardiocentesis

“…This was treated with full anticoagulation with low-molecular-weight heparin. To perform her pericardiocentesis, three possible methods were considered; (1) subcostal approach had overlying liver and abdominal adiposity rendering this conventional access inadvisable, published series indicate an up to 20% complications rate which is also the most indirect route and in current practice it accounts for the bulk of adverse events1 2; (2) apical approach was hindered by breast, chest adiposity and overlying lung with the potential of causing pneumothorax and finally; (3) parasternal approach which is increasingly done in the emergency department by non-cardiologists and was favourable 3. Her echocardiogram (figure 1A) revealed significant effusion around the heart with tamponade physiology on doppler and evidence of diastolic right ventricular collapse.…”