Position and Preparation

• Supine
• Head-of-Bed at 30-45 Degrees (Supports Dependent Fluid Pooling and Brings the Heart Nearer the Chest Wall)
• Prepared Skin with Chlorhexidine or Iodine
• Drape in Standard Fashion
• Inject the Skin with Local Anesthetic
• *Avoid Sedation – Can Rapidly Decompensate Upon Induction

Approaches

• Subxiphoid Approach
  • Insertion: Under the Xiphoid Process
  • Aim: 30-45 Degree Angle Toward the Left Shoulder
• Parasternal Approach
  • Insertion: Left 5^th/6^th Rib Space
  • Aim: Perpendicular
• Apical Approach
  • Insertion: Left 5^th-6^th Rib Space, 5 cm Lateral
  • Aim: 30-45 Degree Angle Toward the Right Shoulder

Procedure

• Perform Under Real-Time Ultrasound Guidance (Preferred) or by Using Landmarks Alone
• Insert Needle with Negative Pressure Applied to the Syringe Until Blood is Aspirated
• Remove the Syringe and Place a Pericardial Drain by Seldinger Technique
  • Insert a Guidewire Through the Needle and then Remove the Needle
  • Dilate the Tract Over the Guidewire
  • Insert a Catheter Over the Guidewire
  • Remove the Guidewire
  • *Pericardial Placement Should Be Confirmed Prior to Drain Placement
• Secure the Drain to the Skin with a Suture an Attach the Drain to a Collection Device

Confirm Pericardial Placement

• Directly Visualize by Ultrasound
• Inject “Agitated” Saline to Assist in Confirmation by Ultrasound
  • Rapidly Mix 9 cc Saline with 1 cc Air Between Two Syringes Immediately Prior to Injection)
  • Layering of Contrast Outside the Heart Confirms Pericardial Placement
• Put Some Aspirated Fluid into a Container and Monitor for Clotting
  • Interventricular Blood Will Clot
  • Pericardial Blood Will Not Clot (Due to the Intrinsic Fibrinolytic Activity of the Pericardium)
• Send Aspirated Fluid for a Blood Gas
  • Interventricular Blood will Have the Respective Blood Gas Values
  • Pericardial Blood will Have a Lower pH, Lower PaO2, and pCO2