Editing Pericardial window


== Closed pericardiocentesis: ==

* Para-apical needle insertion with echocardiographic guidance to assess completeness
* Can also be done sub-xiphoid (lower risk of PTX, but higher risk of damage to intra-abdominal organs). May be difficult in obese patients. 
** Sub-sternally 1cm inferior to left xiphocostal angle
** Once below the cartilage cage, lower the needle to 30 degrees
** Aim towards left mid-clavicle and advance slowly while continuously aspirating
** In most cases, 7-9cm will be adequate, but needles up to 12cm may be needed in obese patients
** If no fluid obtained, withdraw to skin and advance along a more posterior track
** If no fluid still obtained, redirect 10 degrees towards the right and try again, until the needle is aimed toward the right neck
* Remove 50-100mL to assess for improvement
* Insert guidewire and upsize to pigtail catheter

== Pericardial window: ==

* Preparation
** Preferably monopolar if no PPM, but can be done with bipolar (consider LigaSure)
* Can technically be done under LA
* Consider prep and drape prior to GA
* 5-10cm upper midline incision, starting on xiphoid
* Xiphoid lifted or resected
* Extra-peritoneal dissection bluntly towards pericardium
* Sweep cardiophrenic fat pad away bluntly to identify pearly pericardium
* Identify left phrenic nerve (may not be able to see it)
* Grasp pericardium anterior to phrenic nerve between two Ellis then make a pericardiotomy - 4x4cm window
* Place pleural drainage catheter into pericardial space posteriorly (20Fr chest drain on UWSD, tied in like an ICC, coming out lateral to wound)
* If blood gushes and haemodynamic collapse occurs - need left anterolateral thoracotomy

== Post-op: ==

* Keep drain until output <50mL/24 hours

== Pericardial fluid analysis ==

* Higher yield for bacterial infections and malignant effusions
* Most effusions are exudates
* Sanguineous fluid is non-specific, does not indicate active bleeding
* Chylous - traumatic or surgical injury to the thoracic duct, or obstruction by neoplasm
* Cholesterol-rich ('gold-paint') effusions occur in hypothyroidism
* WCC and differential, glucose, protein
* MCS
* Cytology 
* For TB, if suspected: check with lab - specific tests available

== Complications ==

* Cardiac arrest
* Myocardial injury
* Ventricular arrhythmias
* Atelectasis/pneumonia

[[Category:Thoracics]]