CathLabHub

CathLabHub complications toolkitcathlabhub.com/toolkit/tamponade-pericardiocentesisIn review, October 24, 2026

Recognize

The signs on the monitor, the image and the patient.

  • MonitorFalling pressure with a rising right atrial pressure, pulsus paradoxus, and tachycardia that may be missing on beta blockers 1.
  • MonitorProminent x and blunted y descents on the atrial tracing; pulseless electrical activity late 1.
  • EchoEffusion with right atrial and right ventricular collapse, septal shift with breathing and a plethoric IVC 1.
  • ImageContrast collecting around the heart after a perforation; a still cardiac border on fluoroscopy.
  • PatientRestless, short of breath, then gray. As little as 100 mL that accumulates acutely can cause collapse 2.

Act now

In the order the operator does them. The first three come first, whatever else is happening.

  1. Call for help, echo to the room, and say tamponade out loud.
  2. Fluids and vasopressors while you prepare; they buy minutes only 1.
  3. Drain now if the patient is unstable: subxiphoid, echo guided if echo is there, fluoroscopic or ECG guided if not 13.
  4. Seal the source at the same time: a balloon in a perforated coronary 3.
  5. Consider returning the drained blood through a venous sheath (autotransfusion) 3.
  6. Leave a pigtail drain; keep aspirating, as removing as much as possible helps the perforation seal 1.
  7. Reverse anticoagulation only once the source is sealed and the equipment is out 3.
  8. Surgery for ongoing bleeding, clot, loculated or posterior effusions, or a ventricular rupture 14.
  9. Do not drain a tamponade caused by aortic dissection in the lab; it can extend the dissection 1.

Equipment

From the complications cart. Linked items open in the equipment directory.

Drugs

Adult doses as the cited source gives them. Check your formulary and the label.

  • Lidocaine 1 percentLocal anesthesia at the entry site 1.Product in the directory
  • ProtamineAfter the source is sealed and equipment out 3.Weight based dose in the Cath Med App
  • Norepinephrine0.1 to 0.5 mcg/kg/min IV while draining 5.
  • Epinephrine, cardiac arrest1 mg IV every 3 to 5 minutes; drain the pericardium during the arrest 6.

Who to call

The escalation ladder, first call first.

  1. Second operator: one drains, one seals the source.
  2. Echo: to guide the needle and confirm the drain.
  3. Cardiac surgery: as soon as tamponade is recognized after a perforation or a structural injury 3.
  4. Anesthesia: airway and induction carry high risk in tamponade; drain first when you can.
  5. Code team: for pulseless electrical activity.

The bailout step by step

Subxiphoid pericardiocentesis 1

  1. Head of the table up about 30 degrees if the pressure allows 1.
  2. Mark the entry one fingerbreadth below and lateral to the xiphoid, choosing the window closest to the fluid on echo 1.
  3. Local anesthetic; 18 gauge sheathed needle, angled to pass just under the rib margin 1.
  4. Advance with gentle aspiration; when fluid returns, go about 2 mm further and slide the sheath in 1.
  5. Confirm the space: agitated saline on echo, a small contrast puff that pools, or a pressure like atrial pressure; a ventricular waveform means withdraw 1.
  6. J wire into the pericardium, small skin nick, 5 or 6 Fr sheath, then a multihole pigtail 1.
  7. Aspirate to dryness; return blood through a venous sheath if bleeding is brisk 31.
  8. Suture the pigtail, flush every 4 to 6 hours, remove when drainage is under 25 mL a day with no recurrence on echo 1.

Prevent

  • Prevent the perforation: sized balloons, careful wire tips, imaging guided sizing 3.
  • Watch the pressure after every high pressure inflation and every transseptal puncture.
  • Keep the pericardiocentesis tray in the room for complex PCI and structural cases.

After care and documentation

  • Echo before leaving the lab and the next day; the drain usually stays overnight 2.
  • Watch for recurrence after reversal of anticoagulation.
  • Document the volume drained, its color, the approach, the source and the time to drainage.
  • Debrief the team and disclose to the patient and family.

Practice

Emergency simulator cases in the Cath Trainer app. The link opens Cases; type the case number in the search box.

  • EMG-0011: Electrical activity, no arterial waveform
  • EMG-0036: Restless during a long wire run, then unresponsive

References

  1. Sorajja P. Pericardiocentesis. In: Kern MJ, ed. The Interventional Cardiac Catheterization Handbook. 3rd ed. Saunders, Elsevier; 2013. Chapter 18.
  2. Berg R, Lim MJ. Complications of percutaneous coronary interventions. In: Kern MJ, ed. The Interventional Cardiac Catheterization Handbook. 3rd ed. Saunders, Elsevier; 2013. Chapter 4.
  3. Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 26, Perforation.
  4. Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 28, Other complications: hypotension, radiation skin injury, contrast induced acute kidney injury.
  5. Brilakis ES. Manual of Percutaneous Coronary Interventions: A Step-by-Step Approach. Academic Press, Elsevier; 2021. Chapter 3, Medications.
  6. Panchal AR, Bartos JA, Cabanas JG, et al. Part 3: adult basic and advanced life support. 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2020;142(suppl 2):S366-S468.
  7. Holmes DR Jr, Nishimura R, Fountain R, Turi ZG. Iatrogenic pericardial effusion and tamponade in the percutaneous intracardiac intervention era. JACC Cardiovasc Interv 2009;2:705-717.
  8. CathLabHub Cath Trainer app, emergency simulator: case library (cathlabhub.com/app, Cases).

Educational reference for cath lab teams, not medical advice and not a standard of care. Your local policy, the device instructions for use and current guidelines govern. Verify every dose before use. Printed from cathlabhub.com/toolkit/tamponade-pericardiocentesis. First version, in clinical review: an interventional cardiologist is checking every card before it is final. Every number cites its source on the card.