Pericardiocentesis

[waterbottle10]

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In cases where patient develops acute tamponade and becomes unstable, is it our responsibility clinically and/or legally to be doing a pericardiocentesis, or are we supposed to call CT surgery? I personally have never done one in residency, and never have been trained for one, but in cases where you get an acute tamponade and the patient codes, medication/CPR won't really do much. How many of you would just pull out a needle and start stabbing or is this malpractice..

 

[dchz]

I do'nt know the legal answer, as I am not a lawyer.

I also have not practiced under my own license yet because i'm a resident. So what i say might change.

But if I'm caring for the patient, and he's got confirmed tamponade on US there will be a needle to drain it before he dies.

Rule #6:
"There is no body cavity that cannot be reached with a #14G needle and a good strong arm."

 

[AdmiralChz]

In cases where patient develops acute tamponade and becomes unstable, is it our responsibility clinically and/or legally to be doing a pericardiocentesis, or are we supposed to call CT surgery? I personally have never done one in residency, and never have been trained for one, but in cases where you get an acute tamponade and the patient codes, medication/CPR won't really do much. How many of you would just pull out a needle and start stabbing or is this malpractice..

Call a surgeon, immediately. A pericardial window is curative and they can leave a drain in place (while you place an echo to make sure the tamponade is resolved). Also if it’s a bloody, loculated effusion a simple needle drainage is unlikely to remove all of the effusion. But it absolutely can buy you time to get call the surgeon and get to the OR safely.

That being said, if it’s real tamponade and the patient is on the verge of coding you need to do what is necessary for the patient. If a surgeon isn’t there and you can see a large effusion on ultrasound, try to drain it a little to relieve the pressure. Even still you should call for a stat consult as they are likely still going to require surgery if it’s THAT severe. These sorts of situations are pretty rare, to be honest.

I’ve seen this a couple times in residency and now in fellowship - unstable patient develops tamponade and the surgeon is dragging his/her feet not believing you. Get some data, ultrasound and show them the problem to get them moving.

Read up on how to do it, not hard. YouTube is nice. Don’t practice on your friends or stable patients, though.

 

[DocVapor]

Are we talking intra-op or ICU? My answer would probably change as to who would do it, but it's unlikely that answer would be me in either case. I'm just a ca-1 though.

 

[Noyac]

First things first, call surgeon while instituting FAST, FULL and FORWARD.
Then decide the next step. If pt is coding I’d give it a go. If code is imminent I’d give it a go. If the 3 F’s are holding off the code then wait for surgeon.

I look at it like this, I’m not a surgeon but I’ve seen a lot of surgeries and some of them I could probably butcher my way through. This may make “me” the pts best chance at survival just as in the case of a surgical airway. I’m sure a surgeon can do the airway better in terms of less trauma to surrounding tissue but the ultimate goal is survival and if I can do that then I am jumping in.

 

[waterbottle10]

Call a surgeon, immediately. A pericardial window is curative and they can leave a drain in place (while you place an echo to make sure the tamponade is resolved). Also if it’s a bloody, loculated effusion a simple needle drainage is unlikely to remove all of the effusion. But it absolutely can buy you time to get call the surgeon and get to the OR safely.

That being said, if it’s real tamponade and the patient is on the verge of coding you need to do what is necessary for the patient. If a surgeon isn’t there and you can see a large effusion on ultrasound, try to drain it a little to relieve the pressure. Even still you should call for a stat consult as they are likely still going to require surgery if it’s THAT severe. These sorts of situations are pretty rare, to be honest.

I’ve seen this a couple times in residency and now in fellowship - unstable patient develops tamponade and the surgeon is dragging his/her feet not believing you. Get some data, ultrasound and show them the problem to get them moving.

Read up on how to do it, not hard. YouTube is nice. Don’t practice on your friends or stable patients, though.

So you would do a needle drainage if the surgeon is being slow. What if, since I have never done it before, I stab the needle inside the heart instead of the pericardial window? Would that then be malpractice?

Are we talking intra-op or ICU? My answer would probably change as to who would do it, but it's unlikely that answer would be me in either case. I'm just a ca-1 though.

Intra op.

 

[Mman]

So you would do a needle drainage if the surgeon is being slow. What if, since I have never done it before, I stab the needle inside the heart instead of the pericardial window? Would that then be malpractice?

That's why I'm not doing it unless the code is happening/imminent. If the patient is coding aka dying/dead, no harm no foul for stabbing into the ventricle. If the patient is quasi stable at the moment, your botched attempt could cause them to die.

Call for help, manage medically as best you can, and if death imminent then you can throw the hail mary pass.

 

[AdmiralChz]

So you would do a needle drainage if the surgeon is being slow. What if, since I have never done it before, I stab the needle inside the heart instead of the pericardial window? Would that then be malpractice?



Intra op.

I know of anesthesilogists (unsuccessfully) sued for not performing it. He was protected since he argued the surgeon who was standing right there was the expert and should have performed drainage more quickly (no one was found liable - patient was severely ill and unlikely to survive even with prompt drainage); however, the scenario I propose is one where there isnt anyone else nearby. Have you done needle decompression for a tension pneumo? I doubt it, but you should still be familiar with the procedure.

If you stab the heart it probably isn’t a severe compressive tamponade, there can be more than 500-1000mL in the mediastinum in these acute cases so there’s a wide safety margin.

 

[Psai]

I do what I think is right for the patient and what I would want for me. Easy to say when I'm not the one responsible yet though.

 

[anbuitachi]

I know of anesthesilogists (unsuccessfully) sued for not performing it. He was protected since he argued the surgeon who was standing right there was the expert and should have performed drainage more quickly (no one was found liable - patient was severely ill and unlikely to survive even with prompt drainage); however, the scenario I propose is one where there isnt anyone else nearby. Have you done needle decompression for a tension pneumo? I doubt it, but you should still be familiar with the procedure.

If you stab the heart it probably isn’t a severe compressive tamponade, there can be more than 500-1000mL in the mediastinum in these acute cases so there’s a wide safety margin.

That probably depends on baseline heart function? May not need that much fluid if the baseline heart is not super strong

I do what I think is right for the patient and what I would want for me. Easy to say when I'm not the one responsible yet though.

Wait you dont have 50 years of board certified emergent medicine?

 

[Robotic Wis-Hipple]

I know of anesthesilogists (unsuccessfully) sued for not performing it. He was protected since he argued the surgeon who was standing right there was the expert and should have performed drainage more quickly (no one was found liable - patient was severely ill and unlikely to survive even with prompt drainage); however, the scenario I propose is one where there isnt anyone else nearby. Have you done needle decompression for a tension pneumo? I doubt it, but you should still be familiar with the procedure.

If you stab the heart it probably isn’t a severe compressive tamponade, there can be more than 500-1000mL in the mediastinum in these acute cases so there’s a wide safety margin.

Nah, I think it’s the other way, acute tamponade doesn’t take much volume whereas a chronic/subacute etiology allows for stretching/compensation of the pericardium up to a point so total volume is higher. So I’d think risk of inadvertent needle puncture of the ventricle would be higher in acute settings.

With that said, I have watched a surgeon do just that, and it doesn’t lead to the type of disaster you might think. Either way, my desire is to practice in a way that I’m not just going to let a Pt expire in front of me. I will cut the neck, and I would needle aspirate a tamponade. I don’t think there are many people in a hospital better equipped to guide a needle to a black space in an US image than us tbh.

 

[Shimmy8]

Agree with above. Treat it like a surgical airway, i.e., call appropriate surgeon and perform if you feel like it’s in best interest of patient if they’re not they’re yet/available.

 

[B-Bone]

I had the real deal in PACU last year. Patient had some vascular procedure in the neck with multiple wires down the carotid and IJ. Got real tachy in the PACU, BP drifts down, starts to have altered mental status. Happened over about 10 minutes, so not immediate. Had discussed with his surgeons, and they placed a cardiology consult prior to him getting unstable. Once he started to get unconscious/unstable, I intubated him (no drugs) and was starting to give epi. Cardiologist (non-interventional guy) walked in just as we were starting compressions. I already had someone running for a TTE probe, so he took a look and saw a big effusion. I asked him if he wanted to try to needle it or if he wanted me to, and he volunteered (whew!). 14g needle substernal with a stopcock and a 60 cc syringe. We pulled about 200 cc out and watched his a-line give us a waveform again in real time. While we were setting up cath lab for pigtail placement, the effusion recurred and his BP tanked again. Did one more pull for about 300 more ccs with immediate improvement. Stable for transport to cath lab, but did code again while getting set up in cath lab. Pigtail placed stat, and he again stabilized immediately. Turns out vascular guys poked a hole in his RV with their wires. He ended up coming to the OR at about midnight for sternotomy and oversew of hole. That was a fun call night.

If my patient was coding and I thought it might help (and there was no surgeon around), I'd definitely give it a shot.

 

[Mman]

I had the real deal in PACU last year. Patient had some vascular procedure in the neck with multiple wires down the carotid and IJ. Got real tachy in the PACU, BP drifts down, starts to have altered mental status. Happened over about 10 minutes, so not immediate. Had discussed with his surgeons, and they placed a cardiology consult prior to him getting unstable. Once he started to get unconscious/unstable, I intubated him (no drugs) and was starting to give epi. Cardiologist (non-interventional guy) walked in just as we were starting compressions. I already had someone running for a TTE probe, so he took a look and saw a big effusion. I asked him if he wanted to try to needle it or if he wanted me to, and he volunteered (whew!). 14g needle substernal with a stopcock and a 60 cc syringe. We pulled about 200 cc out and watched his a-line give us a waveform again in real time. While we were setting up cath lab for pigtail placement, the effusion recurred and his BP tanked again. Did one more pull for about 300 more ccs with immediate improvement. Stable for transport to cath lab, but did code again while getting set up in cath lab. Pigtail placed stat, and he again stabilized immediately. Turns out vascular guys poked a hole in his RV with their wires. He ended up coming to the OR at about midnight for sternotomy and oversew of hole. That was a fun call night.

If my patient was coding and I thought it might help (and there was no surgeon around), I'd definitely give it a shot.

While that is a cool story, I kinda question the wisdom of cardiology proceeding with pigtail placement after you initially drained it with immediate improvement and then it quickly came back requiring another massive drainage. I mean at that point you kinda know it is actively filling back up and a pigtail doesn't fix the problem.

but that's just Monday morning quarterbacking

 

[B-Bone]

While that is a cool story, I kinda question the wisdom of cardiology proceeding with pigtail placement after you initially drained it with immediate improvement and then it quickly came back requiring another massive drainage. I mean at that point you kinda know it is actively filling back up and a pigtail doesn't fix the problem.

but that's just Monday morning quarterbacking

Agreed. Cardiology was immediately available, CT surgery was not. When they became available, pt went to the OR.

 

[Arch Guillotti]

But if I'm caring for the patient, and he's got confirmed tamponade on US there will be a needle to drain it before he dies.

It isn't an all or none scenario. Not every echo that is read as some degree of tamponade or RV diastolic collapse or whatever is a do or die emergency.

 

[drmwvr]

It isn't an all or none scenario. Not every echo that is read as some degree of tamponade or RV diastolic collapse or whatever is a do or die emergency.

not to put too fine a point on the echo, I'd be more interested in what the LV looked like

 

[leviathan]

It isn't an all or none scenario. Not every echo that is read as some degree of tamponade or RV diastolic collapse or whatever is a do or die emergency.

This. Have seen many patients with echo features of tamponade who were completely fine. Have also seen a patient with an effusion who cardiology were adamant was not tamponade by echo who weaned off their multiple inopressors a minute after it was drained in the OR.

 

[zero0]

Agree with above. Treat it like a surgical airway, i.e., call appropriate surgeon and perform if you feel like it’s in best interest of patient if they’re not they’re yet/available.

How many tracheostomy reps will a run of the mill anesthesiology residency give you anyway? If any. Seems like something that would be good to have a handle on. Honestly, it'd be a great direction for residencies to go in to give us some extra breathing room from those pesky CRNAs.

 

[dchz]

It isn't an all or none scenario. Not every echo that is read as some degree of tamponade or RV diastolic collapse or whatever is a do or die emergency.

obv it's gonna be way closer to just right before he dies, obv don't poke a needle in a stable pt. i thought that was assumed?

This. Have seen many patients with echo features of tamponade who were completely fine. Have also seen a patient with an effusion who cardiology were adamant was not tamponade by echo who weaned off their multiple inopressors a minute after it was drained in the OR.

If the pt crashing and you see it you drain it imo.

obv clinical judgement needs to be used here, but the OP says acute taponade and unstable. i assumed unstable means on the way to morgue, if unstable = 0.04 of norepi makes stable, then don't poke heart.

 

[nlax30]

While that is a cool story, I kinda question the wisdom of cardiology proceeding with pigtail placement after you initially drained it with immediate improvement and then it quickly came back requiring another massive drainage. I mean at that point you kinda know it is actively filling back up and a pigtail doesn't fix the problem.

but that's just Monday morning quarterbacking

I think placing a pigtail at that point is fine. If we cause an effusion/tamponade during an ablation or pacer wire placement we’ll drain it in the lab and place a drainage catheter as we want to see if it continues to re-collect or not. Most of the time small perforations like this resolve on their own and don’t require surgery.

If the surgeon is doing a procedure that could potentially lead to tamponade as a complication then he/she should be able to perform a pericardiocentesis, if not then yea you certainly have to do what you can in a code/peri-code situation.

 

[Noyac]

If you stab the heart it probably isn’t a severe compressive tamponade, there can be more than 500-1000mL in the mediastinum in these acute cases so there’s a wide safety margin.

It’s been a while since I’ve thought about this scenario but the acute case will decompensate with a small amount of blood in the pericardium. Something like 50-100cc can cause big problems. The chronic cases can slowly grow and will tolerate much larger volumes.


Oops. I see others have mentioned this as well. Carry on.

 

[Mman]

I think placing a pigtail at that point is fine. If we cause an effusion/tamponade during an ablation or pacer wire placement we’ll drain it in the lab and place a drainage catheter as we want to see if it continues to re-collect or not. Most of the time small perforations like this resolve on their own and don’t require surgery.

If the surgeon is doing a procedure that could potentially lead to tamponade as a complication then he/she should be able to perform a pericardiocentesis, if not then yea you certainly have to do what you can in a code/peri-code situation.

I guess the ones I've seen that reaccumulate several hundred mls that fast don't resolve on their own quickly.