A novel in-plane technique for ultrasound-guided pericardiocentesis

A case report on ultrasound-guided pericardiocentesis with a right parasternal approach: a novel in-plane lateral-to-medial technique

INTRODUCTION

Emergency pericardiocentesis is a life-saving procedure that is performed to aspirate fluid from the pericardial space in patients who have severe pericardial effusion that is causing hemodynamic compromise. The current gold standard for pericardial fluid aspiration is ultrasound-guided pericardiocentesis. Echocardiography with a low-frequency transducer has generally been used in pericardiocentesis, but this method lacks real-time visualization of the needle trajectory, leading to complications. Therefore, we describe a case involving an ultrasound-guided pericardiocentesis method using a novel in-plane technique with a lateral-to-medial approach via the right parasternal and a high-frequency probe. The method was performed for an infant with cardiac tamponade.

CASE PRESENTATION

We present a case of a 14-month-old male infant who was brought to the emergency room with a history of cough, shortness of breath, and fever following recurrent chest infections. Despite prior treatments, his condition deteriorated, and signs of cardiac tamponade were evident upon examination. Cardiopulmonary point-of-care ultrasound confirmed the presence of a large pericardial effusion with tamponade. Emergency pericardiocentesis was performed using the novel in-plane technique, resulting in successful fluid aspiration and stabilization of the patient's condition.

TECHNIQUE DESCRIPTION

The proposed technique involves positioning a high-frequency ultrasound probe over the right parasternal area to obtain real-time visualization of the needle trajectory and surrounding structures, including the sternum, right internal thoracic vessels, pleural sliding end point, pericardial effusion, and myocardium. The needle is inserted laterally to medially at a 45-degree angle, ensuring safe passage between the pleural sliding endpoint and the right internal thoracic vessels while reaching the pericardial effusion.

CONCLUSION

The presented technique provides real-time visualization of the needle and surrounding structures, which may potentially help to avoid complications and improve accuracy. The proposed technique may potentially enable access for emergency pericardiocentesis and for loculated pericardial effusion that has formed around the right atrium. Nevertheless, further studies with large patient populations are needed.

Use of Point-of-Care Ultrasonography in the NICU for Diagnostic and Procedural Purposes

Point-of-care ultrasonography (POCUS) refers to the use of portable imaging performed by the provider clinician at the bedside for diagnostic, therapeutic, and procedural purposes. POCUS could be considered an extension of the physical examination but not a substitute for diagnostic imaging. Use of POCUS in emergency situations can be lifesaving in the NICU if performed in a timely fashion for cardiac tamponade, pleural effusions, pneumothorax, etc, with potential for enhancing quality of care and improving outcomes.

In the past 2 decades, POCUS has gained significant acceptance in clinical medicine in many parts of the world and in many subspecialties. Formal accredited training and certification programs are available for neonatology trainees as well as for many other subspecialties in Canada, Australia, and New Zealand. Although no formal training program or certification is available to neonatologists in Europe, POCUS is widely available to providers in NICUs. A formal institutional POCUS fellowship is now available in Canada. In the United States, many clinicians have the skills to perform POCUS and have incorporated it in their daily clinical practice. However, appropriate equipment remains limited, and many barriers exist to POCUS program implementation.

Recently, the first international evidence-based POCUS guidelines for use in neonatology and pediatric critical care were published. Considering the potential benefits, a recent national survey of neonatologists confirmed that the majority of clinicians were inclined to adopt POCUS in their clinical practice if the barriers could be resolved.

This technical report describes many potential POCUS applications in the NICU for diagnostic and procedural purposes.

A novel in-plane technique ultrasound-guided pericardiocentesis via subcostal approach

Background

Cardiac tamponade occurs when fluid or blood, fills the pericardial space, and causes hemodynamic compromise due to compression of the heart. It is a potentially life-threatening condition, that requires rapid recognition and immediate treatment. Formerly, blind or surgical techniques were used, and it is associated with complications. Medical technology development has enabled us to perform the procedure safely, with the assistance of ultrasound devices. This article will highlight the novel use of an in-plane subcostal technique, as a safe option for pericardiocentesis in cardiac tamponade.

Case presentation

A 50-year-old man presented to the emergency department (ED) with shortness of breath and shock. He was intubated for respiratory distress. His bedside echocardiography showed cardiac tamponade. Ultrasound-guided pericardiocentesis was carried out using an in-plane technique, at the subcostal region, with a high-frequency linear ultrasound transducer. This particular method provided full visualization of needle trajectory throughout the procedure. It was successfully completed with no complications and patient’s hemodynamic status improved post-procedure. He was successfully discharged on day 13.

Conclusions

The in-plane subcostal pericardiocentesis is a safe, and simple approach that can be performed in the ED for patients with cardiac tamponade. We recommend this new in-plane method, with high-frequency linear transducer at the subcostal area as an alternative when cardiac window for other approaches cannot be visualized.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13089-022-00271-9.

Feasibility and safety of CT-aided pericardiocentesis from a subxiphoid anterior approach by using fluoroscopy in patients with chronic pericardial effusions

Background

Pericardiocentesis is an essential procedure for the diagnosis and treatment of pericardial effusions. The purpose of this study was to evaluate the feasibility and safety of a subxiphoid anterior approach using fluoroscopy aided by a sagittal axis chest computed tomography (CT) view in comparison with an ultrasound‐guided apical approach in patients with chronic pericardial effusion.

Methods

Among 72 consecutive patients (68.8 ± 14.4 years old, 52 males) with hemodynamically stable chronic pericardial effusions, a total of 85 procedures were retrospectively analyzed. We divided them into two groups according to the site of the approach for the pericardiocentesis.

Results

A subxiphoid anterior approach (n = 53) was performed guided by fluoroscopy. The sagittal axis view of the chest CT was constructed to determine the puncture angle and direction for the subxiphoid anterior approach. An apical approach (n = 32) was performed by ultrasound guidance. The success rates of the anterior and apical approaches were 98.1% and 93.8%, respectively. There were two cases with cardiac perforations in the apical approach group, while no cases developed perforations in the subxiphoid anterior approach group.

Conclusion

The subxiphoid anterior approach for pericardiocentesis was feasible and safe for managing chronic pericardial effusions. A reconstruction of the sagittal axis view of the chest CT imaging was helpful to identify the direction and depth to access the pericardial space from the subxiphoid puncture site before the pericardiocentesis using the lateral fluoroscopic view.

The evolution of cardiac point of care ultrasound for the neonatologist

Cardiac point of care ultrasound (POCUS) is increasingly being utilized in neonatal intensive care units to provide information in real time to aid clinical decision making. While training programs and scope of practice have been well defined for other specialties, such as adult critical care and emergency medicine, there is a lack of structure for neonatal cardiac POCUS. A more comprehensive and advanced hemodynamic evaluation by a neonatologist has previously published its own clinical guidelines and specific rigorous training programs have been established to achieve competency in neonatal hemodynamics. However, it is becoming increasingly evident that access and training for basic cardiac assessment by ultrasound enhances bedside clinical care for specific indications. Recently, expert consensus POCUS guidelines for use in neonatal and pediatric intensive care endorsed by the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) have been published to guide the clinicians in using POCUS for specific indications, though the line between cardiac POCUS and advanced hemodynamic evaluation remains somewhat fluid.Conclusion: This article is focused on neonatal cardiac POCUS and its evolution, value, and limitations in the modern neonatal clinical practice. Cardiac POCUS can provide physiological and hemodynamic information in making clinical decisions while dealing with neonatal emergencies. However, it should be applied only for the specific indications and should be performed by a clinician trained in cardiac POCUS. There is an urgent need of developing cardiac POCUS curriculum and certification to support a widespread and safe use in neonates. What is Known: • International training guidelines and curriculum have been published for neonatologist-performed echocardiography (NPE) or targeted neonatal echocardiography (TNE). • International evidence-based guidelines for use of point of care ultrasound (POCUS) in neonates and children have been recently published. What is New: • Cardiac POCUS is increasingly being incorporated in neonatal practice for emergency situations. However, one must be aware of its specific indications and limitations, especially for the neonatal clinical practice. • Cardiac POCUS and NPE/TNE are continuum of cardiac imaging with different indications and training requirements.

Procedural Applications of Point-of-Care Ultrasound in Pediatric Emergency Medicine

Point-of-care ultrasound can improve efficacy and safety of pediatric procedures performed in the emergency department. This article reviews ultrasound guidance for the following pediatric emergency medicine procedures: soft tissue (abscess incision and drainage, foreign body identification and removal, and peritonsillar abscess drainage), musculoskeletal and neurologic (hip arthrocentesis, peripheral nerve blocks, and lumbar puncture), vascular access (peripheral intravenous access and central line placement), and critical care (endotracheal tube placement, pericardiocentesis, thoracentesis, and paracentesis). By incorporating ultrasound, emergency physicians caring for pediatric patients have the potential to enhance their procedural scope, confidence, safety, and success.

International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC)

BACKGROUND

Point-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more important in neonates and children where other monitoring techniques may be unavailable. POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based clinical guidelines for the use of POCUS in critically ill neonates and children.

METHODS

Creation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS and systematic review of relevant literature. A literature search was performed, and the level of evidence was assessed according to a GRADE method. Recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. AGREE statement was followed to prepare this document.

RESULTS

Panellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on moderate quality of evidence (B and C).

CONCLUSIONS

Evidence-based guidelines for the use of POCUS in critically ill neonates and children are now available. They will be useful to optimise the use of POCUS, training programs and further research, which are urgently needed given the weak quality of evidence available.

Ultrasound-guided pericardiocentesis: a novel parasternal approach

Supplemental Digital Content is available in the text.

Objective

The aim of this study was to evaluate a novel pericardiocentesis technique using an in-plane parasternal medial-to-lateral approach with the use of a high-frequency probe in patients with cardiac tamponade.

Background

Echocardiography is pivotal in the diagnosis of pericardial effusion and tamponade physiology. Ultrasound guidance for pericardiocentesis is currently considered the standard of care. Several approaches have been described recently, which differ mainly on the site of puncture (subxiphoid, apical, or parasternal). Although they share the use of low-frequency probes, there is absence of complete control of needle trajectory and real-time needle visualization. An in-plane and real-time technique has only been described anecdotally.

Methods and results

A retrospective analysis of 11 patients (63% men, mean age: 37.7±21.2 years) presenting with cardiac tamponade admitted to the tertiary-care emergency department and treated with parasternal medial-to-lateral in-plane pericardiocentesis was carried out. The underlying causes of cardiac tamponade were different among the population. All the pericardiocentesis were successfully performed in the emergency department, without complications, relieving the hemodynamic instability. The mean time taken to perform the eight-step procedure was 309±76.4 s, with no procedure-related complications.

Conclusion

The parasternal medial-to-lateral in-plane pericardiocentesis is a new technique theoretically free of complications and it enables real-time monitoring of needle trajectory. For the first time, a pericardiocentesis approach with a medial-to-lateral needle trajectory and real-time, in-plane, needle visualization was performed in a tamponade patient population.

Echocardiographic Evaluation of Pericardial Effusion and Cardiac Tamponade

Pericardial effusion (PEff) is defined by an increase in the physiological amount of fluid within the pericardial space. It can appear following different medical conditions, mainly related to inflammation and cardiac surgery. Cardiac tamponade is a critical condition that occurs after sudden and/or excessive accumulation of fluid in the pericardial space that restricts appropriate filling of the cardiac chambers disturbing normal hemodynamics and ultimately causing hypotension and cardiac arrest. It is, therefore, a life-threatening condition that must be diagnosed as soon as possible for correct treatment and management. Echocardiographic evaluation of PEff is paramount for timely and appropriate diagnosis and management. A structured echocardiographic approach including two-dimensional, M-mode, and Doppler echocardiographic evaluation assessing (i) quantity and quality of pericardial fluid, (ii) collapse of cardiac chambers, (iii) respiratory variation of the ventricular diameters, (iv) inferior vena cava collapsibility, and (v) flow patterns in atrioventricular valves should give the bedside clinician the necessary information to appropriately manage PEff. Here, we review these key echocardiographic signs that will ensure an appropriate assessment of a patient with PEff and/or cardiac tamponade.

Pediatric emergency medicine point-of-care ultrasound: summary of the evidence

The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers.  To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations.  Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.

Novel, Long-axis In-plane Ultrasound-Guided Pericardiocentesis for Postoperative Pericardial Effusion Drainage

Pericardial effusion can be a life-threatening complication in children after cardiac surgery. Percutaneous pericardiocentesis is associated with rare, but serious complications. This retrospective study describes our experience with a novel, long-axis in-plane real-time ultrasound (US)-guided technique for postoperative pericardial effusion drainage in small children. Ten out of sixteen procedures were performed within 14 days of cardiac surgery at a median postoperative day 12 (IQR 2, 99). Median age was 2.7 months (IQR 0.4124) and weight 4.5 kg (IQR 2.5, 41.6). All but one procedure required a single attempt. Fourteen out of sixteen procedures had subxiphoid approach, and two were apical. Median initial drainage was 9 mL/kg (IQR 4.5, 27). Fifty percent of effusions were serous, 25 % chylous, and the remainder bloody. There were no reported complications. This study demonstrates a novel, long-axis pericardiocentesis technique that allows for an easy and safe needle entry into the pericardial space for small children in the early postoperative period.

Prehospital ultrasound of the abdomen and thorax changes trauma patient management: A systematic review

BACKGROUND

Ultrasound examination of trauma patients is increasingly performed in prehospital services. It is unclear if prehospital sonographic assessments change patient management: providing prehospital diagnosis and treatment, determining choice of destination hospital, or treatment at the receiving hospital.

OBJECTIVE

This review aims to assess and grade the evidence that specifically examines whether prehospital ultrasound (PHUS) of the thorax and/or abdomen changes management of the trauma patient.

METHODS

A systematic review was conducted of trauma patients who had an ultrasound of the thorax or abdomen performed in the prehospital setting. PubMed, MEDLINE, Web of Science (CINAHL, EMBASE, Cochrane Central Register of Controlled Trials) and the reference lists of included studies were searched. Methodological quality was checked and risk of bias analysis performed, a level of evidence grade was assigned, and descriptive data analysis performed.

RESULTS

992 unique citations were identified, which included eight studies that met inclusion criteria with a total of 925 patients. There are no reports of randomised controlled trials. Heterogeneity exists between the included studies which ranged from a case series to retrospective and prospective non-randomised observational studies. Three studies achieved a 2+ Scottish Intercollegiate Guidelines Networks grade for quality of evidence and the remainder demonstrated a high risk of bias. The three best studies each provided examples of prehospital ultrasound positively changing patient management.

CONCLUSION

There is moderate evidence that supports prehospital physician use of ultrasound for trauma patients. For some patients, management was changed based on the results of the PHUS. The benefit of ultrasound use in non-physician services is unclear.

Looking a bit superficial to the pleura

Background

The internal thoracic artery (ITA) is a descendant branch of the subclavian artery. The former is located bilaterally in both internal sides of the thorax near the sternum and is accompanied by two internal thoracic veins (ITV). From a practical point of view, the ITA (and the ITV) identification is important because these vessels can be injured when pericardiocentesis with the parasternal approach is used. Other advantage of the ITA recognition is to check the patency of the ITA grafts in coronary artery revascularizated patients with new onset chest pain. The purpose of this article is to introduce a simple ultrasonographic technique for recognition of the aforementioned vessels and to highlight the utility of this finding in clinical practice.

Findings

With linear probe and along paraesternal line, the internal thoracic vessels are recognized on grayscale imaging as an anechoic tubular structure immediately anterior to pleural line. Color Doppler identifies a pulsatile (ITA) and a non-pulsatile (ITV) flow. Spectral Doppler normally shows a high resistance velocity profile in non-grafted ITA and a phasic flow in ITV. A biphasic low resistance velocity profile is normally expected in the grafted and permeable ITA.

Conclusions

The ITA (non-grafted) and ITV are recognized routinely along the parasternal line. The operators should identify these vessels when the parasternal approach pericardiocentesis is required and should also consider obtaining spectral Doppler images to check permeability of grafted ITA in coronary artery bypass graft patients with chest pain.