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Large Volume Pericardiocentesis

Dr. Menager, PGY-1 EM resident performed this ultrasound on a 47 yr old man complaining of shortness of breath over the last month, worsening in the last day,  associated with increasing lower extremity edema.

PERIOCARDIOCENTESIS PERFORMED – 1500cc removed from pericardium

A Parasternal Approach – The Steps:

  1. Sterilize
  2. Sedate if there is any chance the patient will move
  3. Look for biggest pocket to tap
  4. Find left lung point so you know where the left lung is and make sure you are away from it
  5. Look for LIMA (don’t go through anything pulsatile!)
  6. Insert catheter above the rib
  8. Insert the catheter and remove the fluid.
lung, lima, rib

How much is too much to take out of the pericardium at one time?  The short answer is that no one knows.  While our patient did just fine, there are case studies of acute systolic ventricular failure following large volume pericardiocentesis.  Whether this is due to a rapid disproportionate increase in right systolic volume compared to left, acute increase in “wall stress”, or the uncovering of previously masked chronic systolic dysfunction is not known (1).  There are only 35 documented cases of this, and according to a 2015 Editorial in the European Heart Journal, “there are no established published methods or studies to propose preventive measures” (2).  Case studies have documented pericardial decompression syndrome (PDS) occurring from removal of as little as 450cc to as much as 2100cc of pericardial fluid.

With high tuberculosis rates here at HUM, we also need to consider that for tuberculosis pericarditis with large pericardial effusions, as described in a 2007 article in the Cardiovascular Journal of South Africa (3), “treatment involves effective drainage of the pericardial space, followed by anti-tuberculosis therapy.”  In this series of 233 consecutive patients with large pericardial effusions who underwent drainage, “on average, more than 800ml of fluid were drained at the initial drainage procedure,” there was not a single complication of pericardial decompression syndrome.

Without good evidence that limited removal of fluid decreases risk or that removal above a certain volume increases risk, you must make a case by case determination of the risk versus benefit ratio.  Whatever your decision, one thing is certain, do monitor these patient extremely closely after the pericardiocentesis is performed!

Dr. Menager demonstrates how to easily and with sterile technique remove large intracorpeal volume of fluid using a three way stop cock and foley bag  (OFF TO BAG –> WITHDRAW FLUID  –> OFF THE PATIENT —> PUSH FLUID INTO BAG  –> repeat).


Subxyhoid View after pericardiocentesis


Apical View of heart after pericardiocentesis (pleural effusion present at right)






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