This means inserting a needle into the pericardial cavity in order to remove excess accumulated fluid or to take exudate for diagnostic examination. Puncture of the pericardium is performed according to indications for purulent pericarditis, in order to clarify the cause of increased production of pleural effusion, with accumulation of blood in the pericardial cavity, air in case of damage to the pleural cavity or chest wall with injuries.

An urgent indication for pericardial puncture is a life-threatening condition - cardiac tamponade. In the case of the development of tamponade - a complete blockage of cardiac activity due to compression of the heart by the contents of the pericardial sac, the doctor needs to act very quickly, which means that he must perfectly master the technique of pericardial puncture. In modern medicine, the technique of pericardial puncture according to Marfan is actively used.

1 Technique of manipulation

When performing a puncture according to Marfan, the doctor performs a puncture at a special point - under the xiphoid process. It must be clearly understood that the puncture site is made strictly in the middle of this anatomical landmark, neither on the left side nor on the right of it. The middle position of the inserted puncture needle ensures its penetration into the pericardial cavity in the region of the right ventricle. The sterile puncture needle should be advanced slowly and smoothly at an angle of 30-45. The needle is directed at first obliquely upward, then slightly posteriorly.

When approaching the region of the heart, the doctor can feel the transmitted pulsation, as well as the feeling of overcoming some obstacle when puncturing the directly external pericardial leaf. When it enters the pericardial cavity, with the aspiration movements of the syringe attached to the needle, the existing contents are removed. Often, a catheter is inserted through a needle into the pericardial cavity, and it is fixed for a certain time (up to 72 hours) to ensure drainage of the cavity and removal of exudate.

If the patient is in a serious condition, during puncturing and introducing a catheter, intrapericardial infusions of medications can be made: prednisolone, hydrocortisone, antibiotics.

2 Preparing the patient

Such a complex, rather dangerous manipulation as pericardial puncture requires preparation of the patient. Before manipulation, the patient needs to make an echocardiogram, radiography of the OGK, and ECG. If the situation is urgent, the list of diagnostic examinations is reduced to radiography or other methods available in the doctor's arsenal. The patient is placed on his back, lifting the bed in the head region. Half an hour before the puncture, the patient is injected with 1 ml of 2% promedol and 0.1% 0.5 ml of atropine for the purpose of anesthesia and sedation.

The skin on the chest is exposed, the existing hairline is shaved off, the operating field is treated with an antiseptic, local anesthesia is performed with 1% lidocaine subcutaneously. As the needle moves deeper, an anesthetic is constantly injected so that the procedure is gentle for the patient in terms of pain. All the time from the beginning of the puncture to its completion, ECG monitoring is performed; by the change in the complexes on the ECG, one can judge the correct technique for performing the manipulation, or about its possible violations.

For example, the appearance of the ST segment elevation on the cardiogram indicates that the needle has come into contact with the myocardium, and damage to the heart muscle during pericardial puncture is a dangerous complication. The procedure can also be performed under ultrasound control. The ultrasound machine allows you to control the course of the puncture needle, as well as to identify the places where the maximum accumulations of pericardial fluid are located. Also, the position of the catheter or needle is monitored when performing a puncture with an X-ray method with contrast.

3 Complications

The access point to the pericardium according to Marfan is relatively safe: this access, with the correct technique, minimizes the possibility of damage to the organs of the mediastinum, pleura, and large vessels. Despite the instrumental methods of monitoring the technician's performance of puncture according to Marfan, complications occur during its implementation. Possible complications during pericardial puncture include:

• damage to the great vessels, myocardium, mediastinal organs with an incorrectly defined Marfan point and a gross violation of technology, which is a medical error;
• the development of arrhythmias;
• drift of infection during puncturing.

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 patient's life.

Fig. 51. Puncture points of the pericardial cavity: I - Sharpe; II - Pirogov; III - Dielafoy; IV - Potexen-Reeder; V - Kurshman; VI - Delorma-Mignon; VII - Larrey; VIII - Marfana; IX - Beitso; X - Voynich-Syanozhetskiy; XI - Roberta; XII - Shaposhnikova

Indications:

· Purulent pericarditis.

Serous pericarditis causing cardiac tamponade

· Receiving pericardial effusion for diagnostic purposes.

Contraindications:

· Relative - the condition after the operation of coronary artery bypass grafting 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 of anesthetic.

5. Long needle (7.5cm).

6. Syringe 20 ml.

7. ECG monitor.

8. Sterile alligator clip.

9. Antiseptic solution for sanitation of the pericardial cavity.

10. Antibiotic for injection into the pericardial cavity.

11. Sterile gloves.

Anesthesia:

1% lidocaine solution or 0.5% novocaine solution

Position:

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

Execution technique:

For puncture of the pericardium, it is necessary to make a chest x-ray, outline the boundaries of the heart shadow and the location of the costophrenic sinus. The puncture is best performed under ultrasound control.

1. Put on sterile gloves, treat with an antiseptic and limit with a sterile towel the site of the intended puncture - the area of \u200b\u200bthe xiphoid process of the sternum - during the puncture of 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, the puncture is performed in the corner 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 a syringe.

5. Along Larrey, direct the needle posteriorly from the sternum, steeply upwards parallel to the sternum, preceding the advancement of the needle with an anesthetic solution, 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. Puncture of the pericardium Fig. 53. Pericardial puncture scheme

by Larrey by Larrey

6. Aspiration may produce blood or effusion. Emptying should be as slow as possible and not completely 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 of the deformation of the QRS complex on the ECG 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 the injected antiseptic 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 continuous drainage, a Teflon # 16 catheter can be used using the Seldinger method.

Possible errors and complications:

It must be remembered that a.mamaria interna is located 1.5-2.0 cm outward from the edge of the sternum. With a puncture 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 the operating room in the presence of an anesthesiologist.

1. For hemothorax or pneumothorax, perform a follow-up chest x-ray. 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). Continuous ECG monitoring is required.

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

10.2. PLEURAL PUNCTION

Often, general surgeons have to deal with chest injuries and diseases when the need for puncture and drainage of the pleural cavity arises. These procedures are quite responsible, at the same time, their timely and correct implementation is an important task, and can save the patient's life.

Indications:

For therapeutic purposes:

Spontaneous pneumothorax;

· Hemopneumothorax with closed chest injuries;

· Tense pneumothorax;

· Acute pyopneumothorax;

Pyothorax;

· Pleurisy of various etiology.

For diagnostic purposes:

· Cytological and bacteriological examination of pleural effusion.

Contraindications: Not.

Equipment:

1. Antiseptic for leather treatment.

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

3. Anesthetic.

4. Sterile gauze balls.

5. Sterile gloves.

6. Syringe 20 ml.

7. Needles no. 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:

Sitting with your hands on a table in front of you or folding your arms across your chest.

Execution technique:

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

2. In case of pneumothorax, puncture is performed 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 \u200b\u200bthe proposed puncture with a skin antiseptic.

5. Numb 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 make a 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 "dip into the void."

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

9. If there is a lot of air or pleural effusion, attach a vacuum suction to the valve or tubing or suction with a 20 ml syringe.

10. If aspiration of the contents of the pleural cavity is performed with a syringe, then when filling the syringe, close the valve or apply a clamp to the drainage tube. Remove the syringe and empty the contents, then reconnect the syringe and open the system.

11. After the end of aspiration of the pleural cavity, sanitize 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 results in significant bleeding into the chest cavity, therefore it is necessary to monitor the patient's hemodynamics. If general symptoms of bleeding appear, repeat the pleural puncture. With significant bleeding, thoracotomy and ligation of the bleeding vessel are necessary.

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

If, during manipulation, air is allowed to enter the pleural cavity and a significant pneumothorax has formed, 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 abdominal organs (liver, spleen). At the same time, creating a vacuum in the syringe, get blood - in this case, it is necessary to change the puncture site. Dynamic observation of the patient is necessary. Bleeding may stop spontaneously, but if general symptoms of bleeding appear, perform an abdominal ultrasound, possibly requiring laparoscopy or laparotomy.

If, during the evacuation of pleural exudate, a cough with bloody or serous-foamy sputum, dizziness, severe chest pain or an admixture of 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 an electric suction, a sudden displacement of the mediastinal organs may occur to their previous position, which leads to serious disorders of blood circulation - 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 your hemodynamic parameters. Give hemodynamic therapy. You may need surgery.

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

The basic rule allowing to avoid 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 dispense more than 1500 ml at a time. And in patients with severe concomitant cardiovascular diseases, the volume of fluid released should not exceed 1000 ml.

Puncture of the pericardium is a complex medical procedure that is performed when a patient develops pericarditis associated with the flow of fluid into the pericardial space. The main task of this procedure is to release the pericardium (pericardial sac) from the accumulated fluid, thereby removing the increased load from the heart.

Indications and contraindications for the procedure

Indications for pericardial puncture in a patient arise when he is diagnosed with pericarditis or. In this case, the procedure allows you to reduce the pressure of fluid on the heart and prevent its further flow into the pericardium.

Pericarditis

If the patient has an exudative stage of pericarditis, then in such a situation, the puncture is carried out solely for the purpose of diagnosing pericardial effusion, and the indications for the treatment of pathology are somewhat different. As for contraindications for puncture, they can occur if the following phenomena are present in the patient's body:

• violation of blood clotting;
• previous coronary artery bypass grafting;
• insufficient pleural effusion;
• obliteration of the pericardial plane.

Important! Indications for the procedure of taking a puncture are established exclusively by one doctor - a cardiac surgeon.

Research methods and stages

Puncture of the pericardium is performed using three different technologies, depending on the location of the puncture point itself:

• Puncture of the pericardium according to Marfan - the needle is inserted into the area under the xiphoid process.
• The method of puncture of the pericardium according to Larrey - the needle enters the area between 8 and 10 pairs of ribs, to the left of the xiphoid process and to the right of the cartilaginous tissue (this technique is considered the most popular of all).
• The procedure for taking a puncture according to Pirogov-Delorm - the needle is inserted into the left chest area between 4 and 5 pairs of ribs.

The technique itself is the same and is carried out in several stages:

• The patient is laid down on a couch in a horizontal position, the upper body is raised 30 degrees. With this elevation, the pleural effusion shifts downward for a more convenient puncture. Before starting the procedure, a small roller is placed under the patient's lower ribs, which fixes the pericardium from below.
• The doctor chooses the point where he will perform the puncture. Most often it is located between the 8 and 10 pair of ribs, since it is in this place that the needle most safely enters the pleural effusion.
• The area where the instrument is inserted, and the needle itself, at least 10-15 cm long, is carefully processed with aseptic means. After complete processing of the instrument and the surface, the doctor begins to perform the procedure for taking a puncture.
• To ensure safety, the needle is inserted strictly perpendicular to the surface of the chest to a depth of 2 cm.Then it is directed towards the back of the sternum upward and recessed for another 2-3 cm.At this stage, the needle is already in the pericardium, and the doctor must understand whether it touches whether her pleural effusion. And this is determined by the synchronous vibration of the needle in time with the heart.

Important! By passing the needle into the pericardium, the doctor can determine what type of pleural effusion is. If the needle falls into the pericardium without much effort, as if into a void, this indicates that the effusion is significant. If, when the needle enters the pericardium, the doctor feels some friction, then in such a situation there is purulent fibrosis.

Removal of excess fluid restores normal hemodynamics, tissues compressed by its pressure. return to their original state, and the patient feels relief.

Possible complications during the procedure

Puncture of the pericardium is not an easy procedure, but if the technique is properly followed, it does not cause any complications in the patient. If the course of the procedure is somewhat disrupted, in this case the doctor may well damage the tissue of the heart, the thoracic or coronary artery of the patient, provoking serious consequences.

If the puncture ends in a medical error, the procedure should be stopped immediately, and an urgent thoracotomy or other surgical measures should be taken. Otherwise, blood from damaged areas may well enter the pericardium, quickly filling it, which in turn will lead to cardiac arrest and death.

Yet:

Features of exudative pericarditis, classification and methods of treatment Symptoms, diagnosis, treatment and prevention of cardiac tamponade

Puncture of the pericardium is called a procedure in cardiac surgery, which is performed to pump out exudate from the pericardial region. The accumulating fluid impairs heart function, so the pericardium is emptied of effusion.

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

Who is it assigned to?

Puncture of the pericardium 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 the threat of a complete cessation of blood circulation.

The following video contains useful information with clear diagrams about pericardial puncture:

Why do the procedure

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

• autoimmune diseases,
• infections,
• renal failure,
• rheumatoid arthritis,
• tuberculosis,
• uremia,
• collagenosis.

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

The procedure cannot be repeated often, as the risk of injury is very high. Moreover, if something goes wrong, it is immediately stopped and the patient is intensively monitored.

Types of diagnostics

Puncture is carried out using several methods:

1. Pirogov-Delorma technique... The needle is inserted at the level between the fourth and fifth ribs on the left side.
2. Pericardial puncture technique according to Larrey... The area between the cartilaginous tissue and the xiphoid process on the left side is pierced. Level - between 8-10 ribs.
3. 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 needle displacement and 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 with, and the second - with effusion pericarditis.

Indications for

It is used for 2 main purposes:

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

Contraindications for

Contraindications for intervention are as follows:

1. coagulopathy,
2. limited effusion
3. low level of platelets in the blood,
4. the 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

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

Preparation for research

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

The cardiac surgeon necessarily marks the future puncture point for puncture of the pericardium, and then checks if it coincides with the location of the heart. For 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 marks the exact puncture site, in which there is a pulsation, friction and noise are heard. Next, a suitable puncturing technique is selected.

The patient before the puncture takes a sitting position. A pillow is placed under the lower back, and the head is tilted back. The chest area in the area of \u200b\u200bthe puncture is treated with alcohol and iodine, and 20 minutes before the start of the intervention, promedol is injected. After the end of this stage of preparation before the puncture, the patient is administered novocaine 0.5% in an amount of 20 ml.

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

Puncture is performed in the deepest region of the pericardium, which helps to eliminate the likelihood of the needle entering the chest cavity. The procedure is carried out in accordance with the chosen method. The exudate from the heart sac is removed by gravity or a syringe, making them aspirate movements.

It is imperative that all actions are carried out 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 withdrawn, processing the puncture site, and then gluing it with glue.

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

You will learn how the pericardial puncture procedure proceeds from the following video:

Deciphering the results of pericardial puncture

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

After it, a number of additional diagnostic studies are assigned to exclude the possibility of damage to any organs. The patient is monitored by a doctor 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 the individual and the clinic. The average cost of the procedure is 15,000.