Iowa Neonatology Handbook: Procedures

Technique for Insertion of a Pericardial Tube

Iowa Neonatology Fellows
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Pneumopericardium generally occurs in infants receiving assisted ventilation or vigorous resuscitation. Pneumopericardium becomes clinically significant when the pericardial air is under enough pressure to impede cardiac output and tamponade the heart.

I. Indications.

A. Pneumopericardium with tamponade.

B. Pericardial effusion with tamponade.

II. Evaluation. Physical examination of an infant with suspected pneumopericardium will reveal tachycardia or bradycardia, muffled or distant heart sounds and decreased blood pressure. Chest x-ray, time permitting, will demonstrate air encircling the heart on both the anterior-posterior and lateral views. The volume of pericardial air seen on x-ray may not correlate with the clinical signs of circulatory compromise. Transillumination is sometimes positive, but pneumopericardium may be confused with pneumothorax or pneumomediastinum.

III. Technique.

A. Cleanse skin over xiphoid, precordium, and upper abdomen with alcohol.

B. Use (1 1/2 inch) 16, 18 or 20 gauge angiocath attached to a 3-way stopcock and 30 cc syringe. If clinical situation permits, consider cutting 1 or 2 small (1 mm) holes (to function as sideports) near end of catheter using blade.

C. Insert the catheter 0.5 cm to the left of and just below the infant's xiphoid, directing it toward left shoulder, aspirating with the syringe as the catheter is advanced. When the pericardial space is entered and air is obtained, remove stylet. Aspiration of air usually results in immediate improvement in hemodynamic status (see figure). 

IV. If air reaccumulates, secure catheter in place and attach to continuous suction via water seal system using 5-10 cm of water in the column. 

V. Confirm catheter position by chest x-ray. 

VI. Potential complications include myocardial puncture or irritation, hepatic laceration, injury to major vessel, pneumothorax, hemothorax, and infection.

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