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