28/06/2025
EMERGENCY PERICARDIOCENTESIS
Subcostal (subxiphoid) — The extrapleural subcostal pericardiocentesis approach is performed as follows
●Introduce the needle substernally 1 cm inferior to the left xiphocostal angle. Once beneath the cartilage cage, lower the needle so it approximates a 15 to 30 degree angle with the abdominal wall.
●Aim the needle toward the left shoulder and advance it slowly while continuously aspirating. If no fluid is aspirated, the needle should be withdrawn promptly and redirected. In the absence of ultrasound guidance, withdraw the needle to the skin and redirect it along a deeper posterior trajectory. The required depth of insertion is affected by the patient's anatomy. In most cases, a 7 to 9 cm needle is adequate, but longer needles (up to 12 cm) may be needed for obese patients. In infants and small children, 4 cm (1.5 inch) needles are sufficient.
If no fluid is aspirated on the second attempt, withdraw the needle to the skin and redirect it 15 degrees to the patient's right of the last dry needle path.
Ultrasound guidance generally enables the clinician to avoid inserting the needle into other organs. However, interposition of the left liver lobe is often recognized on subcostal imaging and the lobe may be traversed intentionally during pericardiocentesis, if an alternative site is not available.
