16-18G sheath for initial entry
inject agitated saline to confirm
5-7 fr introducer or pigtail
J Cardiovasc Ultrasound 1988;7:193 for description of procedure
From Bret Nelson:
In this study, a para-apical approach was deteremined to be the optimal site for paracentesis in 2/3 cases:
Tsang TS, et al.: Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: Clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc 77(5):429–436, 2002.
I think it’s the best one, as it describes actual primary data and experience of the authors performing these procedures. Almost everything else is review articles, book chapters, etc.
Also see these references:
Garth AP, Hwang JQ, Schuur JD, Rosborough S. Ultrasound guided pericardiocentesis of cardiac tamponade. Acad Emerg Med 2009;16:811-811
Salem K, Mulji A, Lonn E. Echocardiographically guided pericardiocentesis — the gold standard for the management of pericardial effusion and cardiac tamponade. Can J Cardiol 1999;15:1251-1255
From Emergency Medicine Procedures:
Many authors feel that ultrasound-guided pericardiocentesis is now the standard of care.14,20,30,31 The exact techniques will vary. The echocardiogram is used to localize the area of the largest effusion. The point of needle insertion will be where the pericardial fluid is maximal. The location and direction of the ultrasound waves should be fixed in the mind of the person performing the pericardiocentesis, and the needle is advanced similarly.32 Alternatively, the transducer may be used to actively guide the placement of the needle.33 The transducer is used to locate the area of largest effusion and the needle is inserted suitably close by and advanced toward the maximal effusion. Proper needle placement can be further confirmed by injecting saline that has been shaken to produce bubbles.32 The bubbles will show well on the ultrasound. Some transducers now come with central lumens designed to accept a pericardiocentesis needle, while others have attachable variable-angle needle guides.30,34
From Current Diagnosis and treament, emergency Medicine, 7th Ed:
Many emergency departments currently utilize bedside ultrasound to detect pericardial effusion. Ultrasound is quick, noninvasive, and can even provide guidance for pericardiocentesis in the symptomatic patient with pericardial effusion. Blind pericardiocentesis should be reserved for those situations in which a critically ill patient is suspected of having tamponade and no diagnostic tests are rapidly available to assist in the diagnosis or treatment.
Ma’s Ultrasound book, 2nd edition describes this technique in the pericardiocentesis chapter:
For the parasternal/apical approach the patient is positioned in the left lateral decubitus position if possible. The largest pocket of fluid is identified and will often be located somewhere between the traditional transducer position for a parasternal view and an apical view (Figure 20-76A and B). A long-axis orientation to the heart is recommended as well as longitudinal needle guidance. Vascular structures should be avoided (locations described above). Local anesthesia should be infiltrated first at the entry site and deeper infiltration should be done along the predetermined trajectory if clinical circumstances allow. The needle should be introduced adjacent to the transducer in the long-axis plane and opposite the probe orientation indicator. The needle to be inserted for aspiration should be a 14- to 18-gauge, 5.1- to 8.3-cm Teflon-sheathed angiocatheter.