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NURSING MANAGEMENT OF
PERICARDIOCENTESIS e.c
PERFORATION
on PCI PATIENT

Danik Rahayu Fardanti, S.Kep.,Ns

Panti Rapih Hospital
Yogyakarta Indonesia
 Potential conflict of interest

Speaker’s name : Danik Rahayu Fardanti, S.kep.,Ns

I do not have any potentisl conflicts of interest
CARDIAC
TAMPONA
DE
Cardiac tamponade is defined
as the decompensated phase
of cardiac compression,
resulting from increased
intrapericardial pressure.
INCIDENCE • Cardiac Tamponade e.c
Iatrogenic Coronary Artery
Perforation is a rare
complication of PCI (0.1-0.4%)
• BUT it is associated with high
morbidity and mortality
• Most cases are recognized in the
Cathlab, but delayed cardiac
tamponade may occur and must
be considered as a cause of late
hypotension after PCI
 Causes
of
CARDIAC
TAMPONAD
E
2015 ESC Guidelines for the diagnosis and management
of pericardial diseases
Sympto Dyspnea
m& Elevate Jugular Venous Pressure
sign:
Hypotension
Tachycardia
Pulsus paradoxus
Muffled heart sound
Low QRS voltages
Clinical management of patients with coronary vessel
perforation following percutaneous intervention

“Martin et.al. Diagnosis, Management, and Clinical Outcome of Cardiac Tamponade

Complicating Percutaneous Coronary Intervention. The American Journal Of Cardiology Vol.
90, 2002”
Clinical management of patients with coronary vessel
perforation following percutaneous intervention

“Gunning, Williams, Jewitt, et al. Coronary artery perforation during

percutaneous intervention: incidence and outcome. 2002”
Recommendation (clinical
diagnosis)
(1)Cardiac tamponade should be suspected in patients presenting
with hypotension, jugular venous distension, pulsus paradoxus,
tachycardia, tachypnea, and/or severe dyspnoea;
(2)Additional signs may include low QRS voltages, electrical
alternans, enlarged cardiac silhouette on chest X-ray.

“ESS : Triage strategy for urgentmanagement of cardiac tamponade: a position statement of the European Society of
CardiologyWorking Group on Myocardial and Pericardial Diseases (2014)”
Recommendation (imaging)
(1) Echocardiography is the diagnostic method of choice in suspected
cardiac tamponade and should be carried out without delay.
(2) CT and CMR are not part of the routine evaluation of patients with
suspected cardiac tamponade; they are useful to rule out
concomitant diseases involving the mediastinum and lungs in patients
with large pericardial effusions (i.e. cancer or aortic dissection).

“ESS : Triage strategy for urgentmanagement of cardiac tamponade: a position statement of the European Society
of CardiologyWorking Group on Myocardial and Pericardial Diseases (2014)”
Recommendation (indication for
drainage)
(1) Pericardial drainage is indicated for each case with established

diagnosis of cardiac tamponade. If the patient is haemodynamically

stable, the procedure should be performed within 12–24 h from

diagnosis, after obtaining laboratory results including the blood counts.

“ESS : Triage strategy for urgentmanagement of cardiac tamponade: a position statement of the European Society of
CardiologyWorking Group on Myocardial and Pericardial Diseases (2014)”
Next……. (indication for
drainage)
(2) Indications for urgent surgical treatment of cardiac tamponade
include hemopericardium due to type A aortic dissection, ventricular
free wall rupture in acute myocardial infarction, trauma, or purulent
effusion in unstable septic patients, and loculated effusions that cannot
be managed percutaneously.

“ESS : Triage strategy for urgentmanagement of cardiac tamponade: a position statement of the European
Society of CardiologyWorking Group on Myocardial and Pericardial Diseases (2014)”
Next……. (indication for
drainage)
(3) In patients with cardiac tamponade, a stepwise scoring system may
be useful for the triage of patients. A total score ≥ 6 warrants
immediate pericardiocentesis in the absence of contraindications. In
rapidly deteriorating patients with iatrogenic hemopericardium or any
other very unstable patient, pericardial drainage should be performed
without any delay for laboratory tests but treating anticoagulation
(protamine), prolonged INR (fresh frozen plasma), and/or anaemia
(plasma-free blood transfusion) simultaneously with the drainage of
the pericardium
“ESS : Triage strategy for urgentmanagement of cardiac tamponade: a position statement of the European
Society of CardiologyWorking Group on Myocardial and Pericardial Diseases (2014)”
Effect of Pericardiocentesis
Significantly increases stroke volume

Reduces intrapericardial and atrial pressures

Permits separation between right and left filling

pressures

Tachycardia and dyspnoea decrease

Arterial pressure increases and pulsus paradoxus

disappears
 Contra- There is no absolute contraindications to
indications pericardiocentesis when cardiac tamponade and shock
occur
Relative contraindications include uncorrected
coagulopathy, anticoagulant therapy, thrombocytopaenia
(PLTc <50,000/mm3)

Aortic dissection and post-infarction rupture of the free

wall are contraindications to needle pericardiocentesis
“Pericardiocentesis in
(surgical tamponade) due to the potential risk of
cardiac tamponade:
indications and
aggravating the dissection or myocardial rupture via
practical aspects. E-
Journal Cardiology
rapid pericardial decompression and restoration of
Practice.Vol. 15, N° 19 - systemic arterial pressure
11 Oct 2017”
Recommendation (guidance for
pericardiocentesis)
(1)Echocardiography is mandatory to guide pericardiocentesis and select the approach

(intercostal vs. subxiphoid), except in case of life-threatening tamponade.

(2)Fluoroscopy can be considered for early diagnosis and rescue pericardiocentesis

especially for iatrogenic effusions after specific interventional techniques (i.e.

radiofrequency ablation, other percutaneous interventions), although

echocardiography should be immediately available as well.

“ESS : Triage strategy for urgentmanagement of cardiac tamponade: a position statement of the European Society of
CardiologyWorking Group on Myocardial and Pericardial Diseases (2014)”
 Fluoroscopy -guided technique
This procedure is standardised and effective but it can only be performed
in Cathlab

Very useful to treat iatrogenic tamponade during percutaneous

procedures

An echocardiographic examination to assess the distribution and amount

of pericardial effusion should always precede the fluoroscopy-guided
procedure, whenever possible
Next,
…..Fluoroscopy  Performed through the subxiphoid approach with
a needle containing a contrast medium, directed
toward the left shoulder at an angle of 30-45° to
the skin.
 Needle position in the pericardial space is
confirmed by the contrast agent medium injection:
the appearance of a sluggish layering of the
contrast medium inferiorly indicates the correct
position
 Soft J-tip guidewire can be introduced.
 It is essential to check the guidewire position in at
least two angiographic projections (lateral view
and anterior-posterior view)
 Echo-guided Technique

Echocardiography-guided pericardiocentesis is a
safe and simple technique

The echocardiography-guided approach allows

defining the position of the effusion, the ideal entry
site and needle trajectory for pericardiocentesis
Puncture Site
Place of Advantages
Description Disadvantages
puncture

“Pericardiocentesis in cardiac tamponade: indications and practical aspects. E-Journal Cardiology Practice.Vol. 15,
N° 19 - 11 Oct 2017”
Next,…Puncture Site
Place of Advantages
Description Disadvantages
puncture

“Pericardiocentesis in cardiac tamponade: indications and practical aspects. E-Journal Cardiology Practice.Vol. 15,
N° 19 - 11 Oct 2017”
Next,….Puncture Site
Place of Advantages
Description Disadvantages
puncture

“Pericardiocentesis in cardiac tamponade: indications and practical aspects. E-Journal Cardiology Practice.Vol. 15, N°
19 - 11 Oct 2017”
Anatomic structures and
approaches
Post-procedure Management
• Aspiration is repeated every 4 to 6
hours

• Catheter can be removed once the

drainage has decreased to less than 25
to 30 ml in 24 hours
• After the procedure, all patients
undergo chest radiography to exclude
the presence of pneumothorax

• Pericardial catheter care is the same as

central venous catheter care
Complications
injury of the cardiac chambers

laceration of the coronary arteries or intercostal vessels

puncture of the abdominal viscera or peritoneal cavity

pneumothorax

Pneumopericardium

Ventricular arrhythmias

Pericardial decompression syndrom

Nurses Role (preprocedure)
• Explaining the procedure to the patient
• Ensuring the patient has a patent venous access device
• Obtaining baseline vital signs
• Placing the patient in semi-fowler position to promote fluid moving to
a dependent position
• Administering sedation and analgesia as prescribed
 Nurses Role (during procedure)
• Monitor patient’s vital signs
• Monitor clinical status to assess for signs and symptoms of
complications
• Preparing Pericardiocentesis set
Pericardiocentesi
s Set
• Sterile drape
• Lidocain 2% 4-5 amp
• Syringe 10 ml’s ; 20 ml’s
• Needle Puncture (Seldienger)
• Soft J-tip Guide Wire
• Dilator 6F – 8F
• Catheter PigTail 6F
• Three-way Stopcock
• Heacting set
Nurses Role (post procedure)
• Ensure that a 12-lead ECG and chest x-ray are performed.
• Continue to monitor vital signs and hemodynamic status until
drainage is negligible (<25 ml over 24 hours) catheter is removed.
• Evaluate the patient’s response to treatment to ensure that signs and
symptoms of cardiac tamponade have resolved.
• Assess the catheter insertion site for signs of infection, including
erythema, edema, increased warmth, pain, or purulent drainage
Mandatory nursing care
1. Volume repletion, or volume expansion, with agents such as blood,
plasma, dextran, or saline may be needed in patients with cardiac
tamponade until therapeutic pericardial effusion drainage can be
performed.8
2. Inotropic agents such as dobutamine, with or without vasodilators,
may be used in some patients with cardiac tamponade to help
reverse hypotension
3. Sedation, such as midazolam, and analgesics, such as fentanyl, may
be prescribed, depending on the patient’s hemodynamic status
Nursing Intervention
• Nurses have a primary role in monitoring patients for any
deterioration in clinical status.
• Keep patients with cardiac tamponade who are hypotensive on bed
rest with their legs elevated above heart level to increase venous
blood return to the heart
• Patients who aren’t hypotensive should be maintained on bed rest in
semi-fowler position or leaning forward
• Assess for respiratory distress and prepare to administer
supplemental oxygen as needed
• Place the patient on continuous cardiac monitoring to assess for
dysrhythmias
Next,….nursing intervention
• Anticipate preparing the patient for emergent pericardiocentesis with
echocardiographic guidancelate onset cardiac tamponade
• Prepare for volume repletion with isotonic solutions such as 0.9%
sodium chloride solution,
• Prepare inotropic support with agents such as I.V. dobutamine,
depending on the patient’s hemodynamic status.
• Monitor intake and output closely, especially hourly urine outputs.
• Monitor and document the amount and characteristics of the drainage
• Monitor the catheter insertion site for signs and symptoms of infection.
Take Home Message
• Recognize signs and symptoms early for Cardiac Tamponade, and
provide therapeutic interventions and supportive therapies for
optimal patient outcome

• Pericardiocentesis can be a potentially life-saving procedure that

carries a high risk of complications. In this regard, imaging support
and the careful planning of the proper entry site are fundamental for
a safe and successful procedure
THANK YOU