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From cardiological manipulations, it is very important to master the technique of pericardial puncture. This procedure has to be performed in emergency cases with cardiac tamponade, as well as with effusion pericarditis. In both cases, this manipulation may be the only way to save the life of the patient.

Fig.51. Puncture points of the pericardial cavity: I - Sharpe; II - Pirogov; III - Dieulafoy; IV - Potexena-Rider; V - Kurshman; VI - Delorme-Mignon; VII - Larrey; VIII - Marfana; IX - Beytso; X - Voynich-Syanozhetsky; XI - Roberta; XII - Shaposhnikova

Indications:

Purulent pericarditis.

Serous pericarditis causing cardiac tamponade

Obtaining a pericardial effusion for diagnostic purposes.

Contraindications:

Relative - condition after coronary artery bypass surgery due to the risk of damage to the shunts.

Equipment:

2. Anesthetic.

3. Sterile towels, napkins, gauze balls.

4. Needle for intradermal and subcutaneous injection anesthetic.

5. Long needle (7.5 cm).

6. Syringe 20 ml.

7. ECG monitor.

8. Sterile alligator clip.

9. Antiseptic solution for sanitation of the pericardial cavity.

10. Antibiotic for introduction into the pericardial cavity.

11. Sterile gloves.

Anesthesia:

1% lidocaine solution or 0.5% novocaine solution

Position:

Lying on the back, with the head end of the bed raised by 30 °.

Technique:

To perform a pericardial puncture, it is necessary to make a chest x-ray, outline the boundaries of the cardiac shadow and the location of the costophrenic sinus. The puncture is best done under ultrasound guidance.

1. Put on sterile gloves, treat with an antiseptic and limit with a sterile towel the place of the proposed puncture - the area of the xiphoid process of the sternum - when puncturing the pericardium according to Larrey or Marfan.

2. Anesthetize the puncture site.

3. For ECG monitoring, attach the chest lead wire to the needle with an alligator clip.

4. According to Larrey, puncture in the angle formed by the xiphoid process of the sternum and the cartilage of the VII rib - or under the xiphoid process along the midline - according to Marfan, with a 25-gauge needle 7-8 cm long attached to the syringe.

5. According to Larrey, direct the needle posterior to the sternum, steeply upwards parallel to the sternum, sending the anesthetic solution to the advance of the needle, constantly creating a vacuum in the syringe. At a depth of 3-4 cm, the passage of an obstacle is felt - the pericardium.

Fig.52. Pericardial puncture Fig.53. Diagram of a pericardial puncture

according to Larrey according to Larrey

6. Blood or effusion may be obtained on aspiration. Emptying should be as slow and incomplete as possible due to the risk of myocardial damage. The rise of the ST segment on the ECG indicates the contact of the needle with the myocardium.

7. The appearance on the ECG of deformation of the QRS complex indicates the contact of the needle with the epicardium.

8. In the presence of purulent exudate, the pericardial cavity must be sanitized with antiseptic solutions (dioxidine, etc.), and the volume of antiseptic administered should not exceed the volume of the evacuated effusion.

9. Before completing the puncture, inject a broad-spectrum antibiotic into the pericardial cavity.

10. For permanent drainage, a No. 16 Teflon catheter placed using the Seldinger technique can be used.

Possible mistakes and complications:

It must be remembered that a.mamaria interna is located 1.5-2.0 cm outward from the edge of the sternum. When puncturing according to Larrey and Marfan, damage to the internal thoracic artery or vein, heart and pleura is possible, therefore, this manipulation is carried out in an operating room in the presence of an anesthesiologist.

1. For hemothorax or pneumothorax, perform follow-up chest x-rays. If necessary, drain the pleural cavity.

2. Damage to the coronary artery or myocardium, which caused cardiac arrest, requires the use of resuscitation measures (emergency thoracotomy and direct heart massage). Constant ECG monitoring is required.

3. Violation of the heart rhythm. Remove the needle, inject antiarrhythmic drugs.

10.2. pleural puncture

Often, general surgeons have to deal with injuries and diseases of the chest when it becomes necessary to puncture and drain the pleural cavity. These procedures are quite responsible, at the same time, their timely and correct implementation is important task and saves the patient's life.

Indications:

For therapeutic purposes:

spontaneous pneumothorax;

hemopneumothorax in closed chest injuries;

tension pneumothorax;

acute pyopneumothorax;

pyothorax;

Pleurisy of various etiologies.

For diagnostic purposes:

Cytological and bacteriological examination of pleural effusion.

Contraindications: No.

Equipment:

1. Antiseptic for skin treatment.

2. Antiseptic for sanitation of the pleural cavity (dioxidine, etc.).

3. Anesthetic.

4. Sterile gauze balls.

5. Sterile gloves.

6. Syringe 20 ml.

7. Needles number 15, 18 and 22.

8. Faucet or rubber tube with cannula.

9. Tweezers.

11. Electric suction or vacuum suction.

12. Bactericidal plaster.

Anesthesia:

0.5% novocaine solution or 1% lidocaine solution.

Position:

Sit with your hands on the table in front of you or fold your arms across your chest.

Technique:

1. Determine the point of puncture of the pleural cavity on the basis of multi-axis fluoroscopy.

2. In case of pneumothorax, puncture in the II intercostal space along the midclavicular line.

3. In the presence of serous effusion, pus or blood, puncture in the VII or VIII intercostal space along the middle or posterior axillary line, or in the V-VI intercostal space along the anterior axillary line.

4. Put on sterile gloves, treat the area of the proposed puncture with a skin antiseptic.

5. Anesthetize the skin, subcutaneous tissue and intercostal muscles.

6. Attach the syringe to a needle with a stopcock or to a rubber tube with a cannula and puncture along the upper edge of the rib, advance the needle, creating a vacuum in the syringe.

7. Penetration into the pleural cavity is felt as a "failure into the void."

8. When pleural contents appear in the syringe, do not move the needle.

9. If there is a large amount of air or pleural effusion, attach a vacuum suction to the tap or tube or aspirate with a 20 ml syringe.

10. If the contents of the pleural cavity are aspirated with a syringe, then when filling the syringe, close the tap or clamp the drainage tube. Remove the syringe and empty the contents, then reconnect the syringe and open the system.

11. After the end of aspiration, sanitize the pleural cavity with an antiseptic and inject a broad-spectrum antibiotic.

12. Apply an aseptic dressing to the puncture site.

Complications and their elimination:

Damage to the intercostal vessels sometimes causes significant bleeding into the chest cavity, so monitoring of the patient's hemodynamics is necessary. If there are general symptoms of bleeding, repeat the pleural puncture. With significant bleeding, a thoracotomy and ligation of the bleeding vessel is necessary.

If the lung is damaged, a hemorrhagic discharge with air bubbles will appear in the syringe. You need to change the direction of the needle.

If, during manipulation, air enters the pleural cavity and a significant pneumothorax is formed, a puncture or drainage of the pleural cavity in the II intercostal space is necessary.

With punctures in the lower intercostal spaces, the needle may penetrate through the diaphragm into the organs abdominal cavity(liver, spleen). At the same time, creating a vacuum in the syringe, you will receive blood - in this case, you need to change the puncture site. Patients need to be monitored closely. Bleeding may stop spontaneously, but if general symptoms of bleeding appear, perform an abdominal ultrasound, possibly laparoscopy or laparotomy.

If, during the evacuation of pleural exudate, a cough with bloody or serous-frothy sputum, dizziness, severe chest pain, or blood in the leaking fluid appears, it is necessary to stop the manipulation and carry out symptomatic therapy.

With the rapid evacuation of a significant amount of exudate, especially if the evacuation is carried out by electric suction, a sudden displacement of the mediastinal organs to their previous position may occur, which leads to serious blood circulation disorders - collapse, fainting, severe shortness of breath and acute heart failure. The development of these complications requires symptomatic therapy.

Rapid evacuation of the contents of the pleural cavity can lead to rupture of superficial vessels located under the pleura or to rupture of vascular adhesions. In this case, there is a clinic of internal bleeding. Monitor hemodynamic parameters. Administer hemodynamic therapy. You may need an operation.

A sudden decrease in intrapleural pressure can lead to rupture of a compressed lung, especially in those places that, due to the presence of a pathological focus, have the least resistance (superficially located cavities, bronchopneumonic foci). In these cases, the pleural cavity becomes infected. There may be a rupture of intracavernous vessels, leading to massive pulmonary hemorrhage. An urgent bronchoscopy is needed, possibly an emergency operation.

The main rule avoiding those specified in paragraphs. 5,6,7,8 complications, is the slow removal of a significant amount of exudate, without forced aspiration. It is necessary to release 1000 ml within 20 minutes. Do not release more than 1500 ml at a time. And in patients with severe concomitant cardiovascular vascular diseases the volume of the released liquid should not exceed 1000 ml.

The indication for diagnostic puncture is the accumulation of fluid (blood, exudate) in the pericardial cavity. Pericardial puncture simultaneously becomes a therapeutic intervention that eliminates cardiac tamponade and affects the inflammatory process.

Pericardial puncture technique

Through subjective, objective, X-ray and ultrasound studies, convincing information is obtained about the pathological accumulation of fluid in the pericardial cavity. Instruments and medicines: 20-gram syringe, fine needles of various lengths, a needle with a diameter of 1.5-2.0 mm and a length of 10-12 cm, a three-way stopcock or a piece of rubber tubing 6-8 cm long with transition cannulas, Sterile gloves and sheets, sterile container with a volume of 100-200 ml, hemostatic forceps, gauze balls. An anesthetic solution for local infiltration anesthesia, antiseptic solutions for treating the skin and washing the pericardial cavity, sterile tubes for collecting exudate for culture and cytological examination, and an electrocardiograph are needed.

Various places on the chest wall and in the epigastrium for puncture of the pericardial sac are proposed. When choosing a puncture site, they are guided by the following considerations: the likelihood of aspiration of fluid from the pericardial cavity, the lowest risk of injury to the pleural sheets, the internal thoracic artery and the heart. A number of methods, in particular, through the burr hole of the sternum, in the V and VI left intercostal space 2-3 cm medially from the left border of absolute cardiac dullness according to Kurshman, are not currently used. More often, the methods of Larrey or Marfan are used. The position of the patient is semi-sitting or horizontal on a flat roller. The skin of the chest and the upper half of the abdominal wall is treated with an antiseptic solution and covered! sterile linen, leaving free zone xiphoid process. Spend local infiltration anesthesia. With the Larrey method, a puncture needle is inserted in the corner between the cartilage of the VII rib and the left edge of the xiphoid process to a depth of 2 cm. Then the pavilion of the needle is tilted down and, at an angle of 30 ° to the skin, the needle is slowly advanced a few more centimeters deep. With the Marfan method, the needle is inserted directly under the apex of the xiphoid process obliquely from the bottom up towards the posterior surface of the sternum. Then the pavilion of the needle is lifted from the skin and the pericardium is pierced. During the procedure, the syringe plunger is pulled all the time. Penetration of the needle into the cavity of the pericardial sac is felt as a failure, blood enters the syringe with hemopericardium and exudate with pericarditis. In lean patients, the puncture depth is 5-6 cm, in obese patients it is 10-12 cm.

When puncturing according to Larrey and Marfan, there is no danger of injury to the pleural sheets. The needle penetrates into the lower anterior part of the pericardial sac, where exudate always accumulates during pericarditis. In process of aspiration liquid freely comes here from the next departments. In the process of fluid removal, the pericardial borders in the puncture zone practically do not change, so the risk of premature displacement of the needle from the bursa cavity is minimal. In addition, the needle is located parallel to the anterior wall of the pericardium and the end of the needle can be retracted from the heart by shifting its pavilion to the abdominal wall. An accidental puncture of the heart through the lower accesses of Larrey and Marfan is less dangerous, since the displacement of the heart along the implanted needle during systole and diastole is not large and does not lead to myocardial rupture. The small branches of the coronary vessels of the diaphragmatic surface of the heart are not damaged. These advantages allow us to consider the methods of Larrey and Marfan as optimal. Relative contraindications to them are pectus excavatum, hepatomegaly and severe flatulence. In order to avoid diagnostic puncture of the pericardium, it is carried out under the control of a cardiac monitor. A sterile standard lead II electrode is attached to the needle and the electrocardiogram is continuously observed. At the moment of contact of the puncture needle with the epicardium, the QRS complex changes dramatically. It is necessary to remove the fluid slowly so that the heart gradually adapts to the changing pressure.

Removal of 80-100 ml of blood from the pericardial cavity in traumatic hemopericardium, as a rule, has a positive effect on hemodynamics. With pericarditis, the exudate is completely aspirated, the cavity is washed with a warm solution; before removing the needle, 200-300 cm 3 of oxygen are injected and. The exudate is sent for bacteriological, cytological and biochemical studies.

Within two hours after the diagnostic puncture of the pericardium, the patient needs the supervision of medical personnel and bed rest.

The danger of the most formidable complication of a diagnostic pericardial puncture - rupture of the heart wall by a needle - is minimal if the intervention technique is observed and the position of the needle end is controlled by hardware.

The article was prepared and edited by: surgeon

Pericardial puncture can be performed with:

a) therapeutic purpose in case of accumulation of blood, serous fluid, pus in the pericardial cavity with the development of cardiac tamponade (exudative pericarditis, heart injury)

b) for diagnostic purposes to determine the type of exudate in effusion pericarditis

Patient position: on the back with a raised head end of the operating table.

Anesthesia: local anesthesia with 0.5% novocaine solution.

Pericardial puncture technique according to Larrey:

1. With a thick long needle, a puncture of the anterior chest wall is made in the left corner between the VII rib and the xiphoid process of the sternum and the needle is advanced perpendicular to the anterior-lateral wall of the abdomen to a depth of 1.5 cm.

2. Then the needle is tilted and at an angle of 45 to the body surface is advanced upward parallel to the posterior surface of the sternum until it penetrates into the anterior-lower sinus of the pericardium (the sensation of pulsation indicates the proximity of the needle tip to the heart).

3. The puncture is performed with a constant retraction of the syringe plunger. The appearance of blood or liquid in the syringe indicates that it has entered the pericardial cavity.

Operations for wounds of the heart.

Heart wounds are accompanied by three main symptoms:

a) intrathoracic bleeding

b) pericardial tamponade

c) violation of cardiac activity.

The right ventricle, adjacent to for the most part its surface to the anterior chest wall.

For heart injuries:

1. Administer intravenously bolus plasma-substituting agents or blood to replenish the volume of circulating blood

2. Eliminate hemopericardium and eliminate cardiac tamponade by pericardial puncture (removal of even 10-15 ml of blood from the pericardial cavity raises blood pressure to 70-80 mm Hg)

3. Perform immediate thoracotomy with suturing of the wound of the heart.

Rice a - stitches on the wound of the heart; the thumb covers the opening of the wound and stops the bleeding. Fig b - sutures on the myocardium without damage to the coronary artery when the heart is injured near it; U-shaped sutures pass under the coronary artery

Technique for suturing wounds of the heart:

1. Left-sided anterolateral thoracotomy in the 4th-5th intercostal space (if necessary, the incision is expanded by crossing several more intercostal cartilages)

2. Opening the pericardium anteriorly or behind the phrenic nerve, aspirating blood and removing its clots

3. If a bleeding wound of the heart is found, it is sutured. To do this, four fingers of the left hand are placed on the back wall of the heart, fixed and slightly raised towards the surgeon, while pressing the wound with the thumb and stopping the bleeding. The right hand sutures the wound with atraumatic needles, the assistant ties them.

For large lacerated wounds of the heart, a wide circular purse-string or U-shaped suture is applied; for atrial wounds, a purse-string suture; when the wound is located next to the coronary arteries, U-shaped sutures under the coronary arteries; . With a hemostatic purpose, fibrin film, autotissues (muscle, pericardium) can also be fixed to the wound. 4. After suturing a bleeding wound, the heart is examined in search of other wounds (especially on the back wall).

5. The pericardium is sutured with sparse interrupted sutures to ensure adequate outflow of blood residues from the pericardium.

6. Revision of the pleural cavity, drainage of the pleural sinuses.

7. Sewing up the wound of the chest tightly in layers, leaving drainage in the pleural cavity.

A pericardial puncture is a procedure in cardiac surgery that is performed to pump out exudate from the pericardial region. The accumulating fluid impairs the work of the heart, so the pericardium is freed from effusion.

Puncture is necessary for pericarditis and a number of other diseases that provoked squeezing of the heart muscle with fluid and interfere with its full-fledged work. So, let's talk about the technique of performing a pericardial puncture, indications for the procedure, a set for it and other features.

To whom is it assigned

Pericardial puncture is indicated if necessary to establish the nature of the appearance of exudate. The procedure is carried out for both adults and children. It is especially required for patients with endangered full stop circulation.

The following video contains useful information with clear schemes about the puncture of the pericardium:

Why do the procedure

Puncture is carried out only in the presence of fluid in the pericardium, which needs to be confirmed by a number of studies. The procedure is required to identify the cause of the exudate. Often, pericardial effusion can indicate:

autoimmune diseases,
infection,
kidney failure,
rheumatoid arthritis,
tuberculosis,
uremia,
collagenosis.

It is also carried out to identify the prerequisites for the appearance.

Often the procedure cannot be repeated, since the risk of injury is very high. Moreover, if something goes wrong, it is immediately stopped, and the patient is placed under intensive observation.

Types of diagnostics

Punctuation is carried out in several ways:

Pirogov-Delorme technique. The introduction of the needle is made at the level between the fourth and fifth ribs on the left side.
Pericardial puncture technique according to Larrey. The area between cartilage tissue and the xiphoid process on the left side. Level - between 8-10 ribs.
Pericardial puncture technique according to Marfan. A needle is inserted in the middle of the xiphoid process (usually under it).

The last two types of puncture are considered the most atraumatic. The risks of premature displacement of the needle, damage to the pleural sheets are minimal. And with an accidental puncture of the heart wall, the risks of complications are small, they do not lead to myocardial rupture.

The procedure is divided into emergency and planned. The first type of intervention is required for, and the second for effusion pericarditis.

Indications for holding

Used for 2 main purposes:

Treatment. Puncture helps to eliminate tamponade and inflammation.
Diagnostics. Needed to establish the cause of pericarditis.

Contraindications for holding

Contraindications for intervention are as follows:

coagulopathy,
limited effusion,
low levels of platelets in the blood
risk of tamponade after the procedure.

It is carried out with extreme caution when:

purulent pericarditis,
thrombocytopenia,
metastatic effusion,
anticoagulant therapy,
post-traumatic hemopericardium.

It should be noted that there are no serious contraindications that can interfere with the puncture. Sometimes doctors have to take risks to prevent circulatory arrest.

Is the method safe

Pericardial puncture is a very serious and responsible intervention, as there is a risk of damage not only to the myocardial wall, but also to the lungs and stomach. There is a danger of a heart attack and of course infection. Therefore, for the procedure, you always need to select an experienced doctor.

Study preparation

The patient undergoes a series of diagnostic procedures designed to accurately determine the presence of exudate in the pericardium.

The cardiac surgeon necessarily outlines the future puncture point for pericardial puncture, and then checks if it coincides with the location of the heart. To do this, the chest is tapped and tapped, the patient is sent for an X-ray examination.

How is the procedure

After a complete diagnosis, the cardiac surgeon notes the exact puncture site, in which there is a pulsation, friction and noise are heard. Next, a suitable puncture technique is selected.

The patient before the puncture takes a sitting position. A pillow is placed under the lower back, and the head leans back. The chest area in the puncture area is treated with alcohol and iodine, and 20 minutes before the start of the intervention, an injection of promedol is given. After the end of this stage of preparation, before puncture, the patient is injected with novocaine 0.5% in an amount of 20 ml.

The puncture needle is selected thin, as the medicine is injected into the pericardial region. At the same time, the depth of its penetration is no more than 4 cm. When puncturing, the penetration of the needle is somewhat deeper - 6 cm, and in obese people it enters to a depth of 12 cm.

Puncture is carried out in the deepest area of the pericardium, which helps to eliminate the possibility of a needle entering the chest cavity. The procedure is carried out in accordance with the chosen method. Exudate from the heart sac is removed by gravity or with a syringe, making aspiration movements with it.

Be sure to perform all actions slowly so that the heart has time to get used to the changing pressure. Up to 400 ml of fluid is removed from the pericardial cavity during puncture. At the end of the procedure, the needle is removed, treating the puncture site, and then sealing it with glue.

The area where the procedure will be performed is anesthetized, so the patient does not feel anything.

You will learn about how the pericardial puncture procedure takes place in the following video:

Interpretation of the results of a puncture of the pericardium

To prevent heart injury, puncture is carried out under the control of a heart monitor and ultrasound. A sterile electrode is attached to the needle, which allows you to observe the work of the heart muscle continuously. The puncture lasts about 60 minutes.

After it, a number of additional diagnostic studies are prescribed to exclude the possibility of damage to any organs. The doctor watches the patient for some time, measuring breathing, pressure and pulse. The patient himself must comply with bed rest.

Average cost of the procedure

The cost of a puncture depends on individual characteristics and clinics. average price procedure is at the level of 15000.

Cardiac surgery is a branch of medicine that allows you to regulate the work of the heart through surgical intervention. She has many different heart surgeries in her arsenal. Some of them are considered quite traumatic and are carried out for therapeutic purposes according to acute indicators. But there are also such types of cardiological operations as pericardial puncture, which do not require opening the sternum and penetration into the heart cavity. This rather informative mini-operation can be performed for both therapeutic and diagnostic purposes. And, despite all the seeming simplicity of execution, it can even save a person's life.

Indications

Pericardial puncture (pericardiocentesis) is an operation, the essence of which is to remove exudate from the pericardial sac. It must be understood that a certain amount of fluid is constantly in the pericardial cavity, but this is a physiologically determined phenomenon that does not negative impact to the work of the heart. Problems arise if there is more fluid than usual.

The operation to pump fluid from the pericardial sac is performed only if preliminary diagnostic studies confirm the presence of an effusion in it. The presence of a large amount of exudate can be observed with an inflammatory process in the pericardium (pericarditis), which in turn can be exudative or purulent if a bacterial infection is attached. With such a type of pathology as hemopericardium, a significant amount of blood cells is present in the exudate and the pumped out liquid is red.

But pericarditis also does not occur on its own. Effusion in the pericardial cavity can provoke both cardiac pathologies, for example, myocardial infarction, and diseases not associated with the cardiovascular system. Such diseases include: renal failure, rheumatoid arthritis, tuberculosis, collagenosis, uremia. Doctors sometimes observe a similar situation with autoimmune and oncological pathologies. In addition, the presence of purulent exudate in the pericardium can be associated with the presence of a bacterial infection in the patient's body.

Some readers may have a fair question, why pump out fluid from the pericardial sac, if its presence there is considered a physiologically determined phenomenon? Not a large number of fluid cannot interfere with the work of the heart, but if its volume increases rapidly, creating pressure on a vital organ, it becomes harder for it to cope with its functions, cardiac tamponade develops.

Cardiac tamponade is a state of cardiogenic shock that occurs if the pressure in the pericardial cavity becomes higher than the blood pressure in the right atrium, and during diastole and in the ventricle. The heart is compressed and becomes unable to provide an adequate ejection of blood. This leads to a noticeable violation of blood circulation.

If the effusion in the pericardium is formed slowly, then gradually a large amount of exudate accumulates in the pericardial sac, which again can provoke cardiac tamponade. In this case, excessive compression of the heart with a large volume of fluid can lead to a critical decrease in blood flow, which requires immediate intervention to save the patient's life.

In all the cases described above, pericardial puncture is performed to prevent (elective) or treat (emergency) cardiac tamponade. But this procedure also has a high diagnostic value, therefore, it can be prescribed to identify the nature of the exudate in case of suspected pericarditis, which, as we already know, can have various forms.

Training

No matter how easy the procedure for pumping fluid out of the pericardial cavity may seem, it can be carried out only after a serious diagnostic study of the work of the heart, which includes:

Physical examination by a cardiologist (studying the history and complaints of the patient, listening to tones and murmurs in the heart, tapping its boundaries, measuring blood pressure and pulse).
The delivery of a blood test, which allows you to identify the inflammatory process in the body and determine the indicators of blood clotting.
Conducting electrocardiography. With a disturbed pericardial effusion, certain changes will be noticeable on the electrocardiogram: signs of sinus tachycardia, a change in the height of the R wave, which indicates a displacement of the heart inside the pericardial sac, low voltage due to a decrease electric current after passing through fluid accumulated in the pericardium or pleura.
Additionally, central venous pressure can be measured, which is increased in pericarditis with a large effusion.
Ordering a chest x-ray. On x-ray film, an enlarged silhouette of the heart will be clearly visible, having rounded shapes and dilated caudal vena cava.
Echocardiography. It is carried out on the eve of the operation and helps to clarify the cause of the disturbed effusion, for example, the presence of a malignant neoplasm or a rupture of the left atrial wall.

Only after the diagnosis of pericarditis is confirmed or an accumulation of exudate in the pericardial cavity is detected, an emergency or planned operation is prescribed to take fluid from the pericardial sac in order to study it or facilitate the work of the heart. The results of instrumental studies allow the doctor to outline the proposed pericardial puncture points and decide on the actual methods of performing the operation.

During a physical examination and communication with your doctor, you must tell him about all the medications you take, especially those that can reduce blood clotting (acetylsalicylic acid and other anticoagulants, some anti-inflammatory drugs). Usually, during the week before the operation, doctors forbid taking such medicines.

In diabetes, it is imperative to consult about taking hypoglycemic medications before performing a pericardial puncture.

This is about drugs, now let's talk about nutrition. The operation must be performed on an empty stomach, so the consumption of food and even water will have to be limited in advance, which the doctor will warn about at the stage of preparation for surgery.

Even before the start of the operation, the medical staff must prepare all the necessary medicines used during this procedure:

antiseptics for treating the skin in the puncture area (iodine, chlorhexidine, alcohol),
antibiotics for administration into the pericardial cavity after removal of purulent exudate (with purulent pericarditis),
anesthetics for local injection anesthesia (usually lidocaine 1-2% or novocaine 0.5%),
sedative drugs for intravenous administration (fentanyl, midazolam, etc.).

Pericardial puncture is carried out in a specially equipped room (operating room, manipulation room), which must be equipped with all the necessary tools and materials:

A specially prepared table on which you can find all the necessary medicines, a scalpel, surgical thread, syringes with needles for anesthesia and pericardiocentesis (20 cc syringe with a needle 10-15 cm long and about 1.5 mm in diameter).
Sterile clean consumables: towels, napkins, gauze swabs, gloves, gowns.
Dilator, sterile clamps, exudate tube (with a large volume of fluid, if it will be removed naturally), a drainage bag with adapters, a large catheter, a guidewire made in the form of the letter "J".
Special equipment for monitoring the patient's condition (electrocardiomonitor).

Everything should be prepared in the office for urgent resuscitation, after all, the operation is performed on the heart and complications are always possible.

Pericardial puncture technique

After the preparatory part of the procedure is over, proceed directly to the operation. The patient is located on operating table reclining on the back, i.e. top part his torso is raised relative to the plane by 30-35 degrees. This is necessary so that the accumulated fluid during manipulations is in the lower part of the cavity of the pericardial sac. A pericardial puncture can also be performed in a sitting position, but this is less convenient.

If the patient is visibly nervous, sedatives are administered, most often through a venous catheter. The fact is that the operation is performed under local anesthesia, and the person is conscious all this time, which means that he can see what is happening to him and react inadequately.

Next, the skin in the puncture area is disinfected with an antiseptic ( Bottom part chest and ribs on the left side). The rest of the body is covered with clean linen. The needle insertion site (skin and subcutaneous layer) is chipped with an anesthetic.

The operation can be carried out in several ways. They differ in the place of insertion of the needle and its movement to reach the pericardial wall. For example, according to the Pirogov-Karavaev method, the needle is inserted into the region of the 4th intercostal space on the left side. The pericardial puncture points are located 2 cm laterally from the sternum.

By Delorme-Mignon method the puncture should be located along the left edge of the sternum between the 5th and 6th ribs, and the pericardial puncture points according to the Shaposhnikov method near the right edge of the sternum between the 3rd and 4th ribs.

The most common, due to their low traumatism, are the methods of Larrey and Marfan. When using them, the risk of damage to the pleura, heart, lungs or stomach is minimal.

Pericardial puncture according to Larrey implies a puncture of the skin near the xiphoid process on the left side in the place where the cartilages of the VII rib adjoin it (the lower part of the xiphoid process). First, the puncture needle is inserted perpendicular to the body surface by 1.5-2 cm, then it abruptly changes direction and goes parallel to the plane in which the patient lies. After 2-4 cm, it rests against the wall of the pericardium, the puncture of which is carried out with a noticeable effort.

Further, there is a sensation of movement of the needle in the void (resistance is practically absent). This means that it has penetrated into the pericardial cavity. By pulling the syringe plunger towards you, you can see the liquid entering it. For diagnostic sampling of exudate or pumping out a small amount of liquid, a 10-20 cc syringe is enough.

Puncture must be done very slowly. The movement of the needle inside the body is accompanied by the introduction of an anesthetic every 1-2 mm. When the syringe needle has reached the pericardial cavity, a small dose of anesthetic is additionally injected, after which aspiration (exudate pumping) is started.

The movement of the needle is controlled on the monitor using a special electrode attached to it. True, doctors prefer to rely on their feelings and experience, because the passage of a needle through the wall of the pericardium does not go unnoticed.

If a rhythmic twitching of the syringe is felt, the needle may be stuck in the heart. In this case, it is slightly retracted and the syringe is pressed closer to the sternum. After that, you can safely proceed to remove the effusion from the pericardial sac.

If a pericardial puncture is performed for medicinal purposes if purulent pericarditis is suspected, after pumping out the effusion, the pericardial cavity is treated with an antiseptic, in an amount not exceeding the amount of pumped out exudate, and then oxygen and an effective antibiotic are injected into it.

Pericardial puncture at the ambulance stage can be carried out in conditions where there is a large amount of exudate that poses a danger to the patient's life. One syringe is not enough. After removing the needle from the body, a conductor is left in it, a dilator is inserted into the injection hole and a catheter with clamps is inserted through the conductor, to which the drainage system is attached. Through this design, fluid is subsequently removed from the pericardial cavity.

The catheter at the end of the operation is tightly attached to the patient's body and left for certain time during which the patient will be in a medical facility under the supervision of a doctor. If the liquid is pumped out with a syringe, then at the end of the procedure, after removing the needle from the body, the puncture site is briefly pressed and sealed with medical glue.

Pericardial puncture according to Marfan carried out in a similar way. Only the needle for pericardiocentesis is inserted obliquely under the apex of the xiphoid process and moves towards the posterior sternum. When the needle rests against the pericardium sheet, the syringe is slightly removed from the skin and the wall of the organ is pierced.

The duration of the procedure for removing fluid from the pericardial sac can vary from 20 minutes to 1 hour. The exudate is pumped in a little, giving the heart the opportunity to get used to changes in pressure outside and inside. The depth of penetration to a large extent depends on the constitution of the patient. For thin people, this figure ranges from 5-7 cm, for full people, depending on the thickness of the subcutaneous fat layer, it can reach 9-12 cm.

Contraindications for carrying out

Despite the fact that the puncture of the pericardium is a serious and somewhat dangerous operation, it is performed at any age. The neonatal period is no exception, if there are no other ways to restore coronary blood flow in a baby in whose pericardium fluid accumulates.

The operation has no age restrictions. As for health restrictions, there are no absolute contraindications here either. If possible, you should try to avoid such an operation with poor blood clotting (coagulopathy), dissection of the central aorta, low platelet count. However, if there is a risk of serious circulatory disorders, doctors still resort to puncture treatment.

A pericardial puncture is not performed if the disease is not accompanied by a large effusion or rapid filling of the pericardial sac with secreted exudate. It is impossible to carry out a puncture even if after the procedure there remains a high risk of cardiac tamponade.

There is certain situations requiring special care when performing a puncture. Very carefully carry out the removal of bacterial exudate from the pericardial cavity with purulent pericarditis, with effusion associated with oncological pathologies, in the treatment of hemopericardium, which develops as a result of injury or trauma to the chest and heart. Complications are possible during the operation and in patients with thrombocytopenia (due to the low concentration of platelets, the blood does not clot well, which can lead to bleeding during surgical procedures), as well as in those who, according to indications, shortly before the operation took anticoagulants (drugs that thin blood and slow its clotting).

Consequences after the procedure

Pericardial puncture is a cardiac surgical procedure that, like any other heart surgery, has certain risks. The unprofessionalism of the surgeon, ignorance of the methodology of surgical intervention, violation of the sterility of the instruments used can lead to disruption of the work of not only the heart, but also the lungs, pleura, liver, and stomach.

Since all manipulations are carried out using a sharp needle, which, when moving, can damage nearby organs, not only the surgeon's caution is important, but also knowledge of the ways in which the needle can freely enter the pericardial cavity. Still, the operation is carried out almost blindly. The only way to control the situation is monitoring with ECG and ultrasound devices.

The doctor should try not only to strictly follow the methodology, but also to show incredible accuracy. Trying to forcefully pass through the wall of the pericardium, you can overdo it and rest the needle against the heart membrane, damaging it. This cannot be allowed. Feeling the pulsation of the heart through the twitching of the syringe, you must immediately withdraw the needle back, letting it slightly obliquely into the cavity with exudate.

Before the operation, a thorough examination of the boundaries of the heart and its work is mandatory. Puncture should be done in the place where there is a large accumulation of exudate, with aspiration, the rest of the intracavitary fluid will also be pulled up to it.

A responsible approach to the choice of the method of puncture of the pericardial sac is also important. Although the Larrey method is preferable in most cases, however, with some deformities of the chest, a greatly enlarged liver, encysted pericarditis, it is worth thinking about other methods of performing a pericardial puncture that will not have unpleasant consequences in the form of damage to vital organs with a needle or incomplete exudate removal .

If the operation is performed in accordance with all the requirements of an experienced surgeon, the only consequence of such a procedure will be the normalization of the heart due to a decrease in the pressure of the pericardial fluid on it and the possibility of further effective treatment existing pathology.

Complications after the procedure

In principle, all possible complications that develop in the days following the operation have their origin even during the procedure. For example, damage to the cardiac myocardium or large coronary arteries can lead to cardiac arrest, which requires urgent intervention by resuscitators and appropriate treatment in the future.

Most often, the right ventricular chamber is damaged by a needle, which can provoke, if not cardiac arrest, then ventricular arrhythmias. Cardiac arrhythmia may also occur during the movement of the conductor, which will be reflected on the heart monitor. In this case, doctors are dealing with an atrial arrhythmia that requires immediate stabilization of the condition (for example, the administration of antiarrhythmic drugs).

A sharp needle in careless hands along the way can damage the pleura or lungs, thereby causing pneumothorax. Now the accumulation of fluid can be observed in the pleural cavity, which will require identical drainage measures (fluid pumping out) in this area.

Sometimes, when pumping out the liquid, its staining in red is detected. This can be both exudate in hemopericardium, and blood as a result of damage to the epicardial vessels by the needle. It is very important to determine the nature of the pumped liquid as soon as possible. In case of vascular damage, the blood in the composition of the exudate still quickly clots when placed in a clean dish, while the hemorrhagic exudate loses this ability even in the pericardial cavity.

Needle perforation may also affect other vital important organs: liver, stomach and some other abdominal organs, which is very dangerous complication, which can lead to internal bleeding or peritonitis, requiring urgent measures to save the patient's life.

Maybe not so dangerous, but still an unpleasant consequence after the pericardial puncture procedure, the wound becomes infected or the infection enters the cavity of the pericardial sac, which leads to the development of inflammatory processes in the body, and sometimes can even cause blood poisoning.

To avoid possible complications it is possible, if you strictly adhere to the technique of puncture treatment (or diagnostics), to carry out all the necessary diagnostic studies, to act confidently, but carefully, without haste, fuss and sudden movements, to comply with the requirements of absolute sterility during the operation.

Care after the procedure

Even if at first glance it seems that the operation was performed successfully, the possibility of hidden injuries cannot be ruled out, which will later remind of themselves as big troubles, both for the patient and for the doctor who performed the surgery. In order to exclude such situations, as well as, if necessary, to provide timely emergency care the patient, after the procedure, an x-ray examination is mandatory.

AT medical institution the patient may stay for several days or even weeks after the procedure. If it was a diagnostic procedure that went without complications, the patient can leave the hospital the very next day.

In the event of complications, as well as the installation of a catheter that will drain fluid even after surgery, the patient will be discharged only after his condition stabilizes and the need for drainage disappears. And even in this case, experienced doctors prefer to play it safe by conducting an additional ECG, computed tomography or MRI. Carrying out tomography is also indicative for detecting neoplasms on the walls of the pericardium and assessing the thickness of its walls.

During recovery after a pericardial puncture, the patient is under the supervision of the attending physician and junior medical staff, who regularly measures the pulse, blood pressure, monitors the patient's breathing characteristics in order to detect possible deviations that were not detected by X-ray in time.

And even after the patient leaves the clinic, at the insistence of the attending physician, he will have to adhere to certain preventive measures that prevent complications. It's about on the revision of the diet and diet, the rejection of bad habits developing the ability to rationally respond to stressful situations.

If the pericardial puncture has a therapeutic purpose, the patient may stay in the clinic until the end of all medical procedures that can only be carried out in a hospital setting. Carrying out a mini-surgery for diagnostic purposes will give the doctor a direction for further treatment of the patient, which can be carried out both in a hospital setting and at home, depending on the diagnosis and the patient's condition.