Cardiology In Critical Care

Pericardiocentesis

A. Essential Information

  1. Critical Care, Heart, Lung, Blood, and Neuro. Nursing Service Standards of Practice for Cardiovascular Assessment
  2. Critical Care, Heart, Lung, Blood, and Neuro. Nursing Service Standards of Practice for Physical Safety
  3. 10D ICU Emergency Response Program
  4. Nursing Department Standards of Practice for the Care of a Patient with a Pericardial Pigtail Catheter

B. Equipment

  1. 1. Defibrillator with monitor
  2. Pericardiocentesis kit (Mansfield catheter).
  3. 3 60cc luer-lock syringes
  4. Empty evacuated container, 1000cc
  5. Thorocentesis set, 30 inch tubing
  6. Betadine, sterile gloves
  7. Emergency medications: atropine, lidocaine, epinephrine
  8. Sedating medications
  9. Frequent vital signs sheet
  10. Pigtail catheter (if applicable)
    a. 7 Fr for adult patients
    b. 5.5 Fr for pediatric patients

STEPS

1. Admit patient to the Critical Care Unit and perform assessment.
Identify physical assessment findings consistent with cardiac tamponade.

2. Ensure patent IV access. If no IV access, initiate venipuncture
per Nursing Department procedure.

3 Patient in supine position with HOB elevated 30-45 degrees as tolerated.

4 Premedicate patient as ordered.

5. Apply cardiac monitoring leads, non- invasive BP cuff and pulse
oximetry onto patient.

6. Using sterile technique, assist the physician with connecting one
end of the alligator clip to the pericardio-centesis needle; the other end
of the alligator clip is attached to the metal part of the chest (V) lead of the
defibrillator/monitor.

7. Continuously monitor and record the following changes q 5 minutes
during needle insertion, fluid withdrawal, and withdrawal of the needle:
EKG changes, vital signs, and pulmonary artery pressures (if available).
Immediately notify physician of abnormalities.

8. Monitor patients comfort level. Notify physician of discomfort
and administer sedatives/analgesics as ordered.

9. Administer emergency medications as ordered.

10. Assess patient for the following complications:
a. Hypotension
b. Ventricular puncture
c. Cardiac arrest
d. Pulseless electrical activity
e. Pneumothorax
f. Liver laceration

POST PROCEDURE

11. Obtain 12 lead EKG and Chest X-Ray.

12. Assess for signs indicating resolution of tamponade.


13. if pigtail catheter is inserted, ensure that it is sutured in place,
taped securely to the skin, and a sterile, occlusive dressing is applied.

14. Assess for bloody fluid with presence of indwelling catheter.

15. Ensure pericardial fluid is sent to lab for the ordered tests.

KEY POINTS

1. Signs of cardiac tamponade include, but not limited to the following:
distended neck veins, decreasing blood pressure, narrowing pulse
pressure, muffled heart sounds, pulses paradoxus, and equalization
of hemodynamic pressures.



6. Be sure to remove on the V lead before attaching the
alligator clip.


7. EKG changes may include ST elevation (indicating that the
needle penetrated cardiac wall) and dysrhythmias. Vital sign
changes include a widening pulse pressure which would indicate
resolution of tamponade and hypotension related to the amount
of blood or fluid removed.



11. To assess for resolution of the tamponade and the
development of a pneumothorax.

12. Signs of resolution of tamponade include:
a. improved/resolvng dyspnea
b. normalization of vital signs and hemodynamics and
c. the absence of JVD.


14. Continuous bleeding may indicate heart injury.

15. Common tests include: cell count, differential,
glucose, protein, LDH, gram stain and C&S, AFB smear and culture.

D. Documentation

  1. Document the following on a frequent vital signs flow sheet:
    a. All vital signs obtained more frequently than every 15 minutes.
  2. Document the following on the approved Critical Care Flow Sheet:
    a. All medications administered to the patient.
    b. Vital signs obtained every fifteen minutes or less frequently.
  3. Document the following in the Nursing Notes:
    a. Nine category systems assessment.
    b. EKG rhythm changes.
    c. Pain/discomfort/anxiety.
    d. Pericarcial fluid: amount, color, clarity, and odor.
    e. How well the patient tolerated the procedure.
    f. Any complications.

REFERENCES:

  1. Barbiere, C.C., "Cardiac Tamponade: Diagnosis and Emergency Intervention", Critical Care Nurse, Vol. 10:4, 1990, pp. 20-22.
  2. Boggs, R.Ll, Wooldridge-King, M, Editors, AACN Procedure Manual for Critical Care, Third Edition, W. B. Saunders Company, Philadelphia, 1993, pp. 434-437.
  3. 3. Joiner, G.A., , Kolodychuk, G.R., "Neoplastic Cardiac Tamponade", Critical Care Nurse, Vol. 11:2,1991, pp. 50-58.
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