• Procedure to remove fluid from the pericardial space for diagnostic and therapeutic purposes.
  • This is considered a lifesaving procedure for patients presenting with cardiac tamponade.

Techniques to access pericardial space

  1. Blind Procedure: Rarely performed with the advent of ultrasound. Can be done in a code blue or trauma situation.  This procedure is typically done via subcostal approach.
  2. Static Ultrasound: Using the ultrasound, visualize the best fluid pocket and estimate the angle of approach for needle insertion.  Needle is inserted without direct ultrasound guidance.
  3. Dynamic Ultrasound: Direct visualization of the needle entering the pericardium. This technique is technically challenging due to the need to visualize the needle in-plane with the ultrasound beam and guide it into the pericardial space. (this is the technique we teach on!)
  4. Fluroscopically guided: Usually done in the cath lab with direct visualization of the needle with x-ray guidance.  Radio-contrast is injected through the needle to confirm position in the pericardial space.

Dynamic Ultrasound Technique Video

NOTE: Recommend watching the video in full-screen mode


  1. Confirm window:
    • Ultrasound patient to select the appropriate window (apical, parasternal, or subcostal), and identify relevant structures.
    • Practical tip: Use the window that allows access to the largest pocket of fluid that is clear of other structures to reduce risk of complications (ie. hepatic laceration or pneumothorax)
  2. Preparation:
    • Collect supplies and position the patient supine with the head of the bed raised to 30-45 degrees
    • Sterilize the skin and create a sterile environment
  3. Anesthetize Skin
    • Freeze skin with 1-2% lidocaine to anesthetize the skin overlying the needle entry site.
  4. Micropuncture needle insertion
    • The micropuncture needle is inserted under dynamic in-plane ultrasound guidance.  Periodic or continuous negative pressure is applied to detect when the needle tip enters the pericardial space.
    • Practical tip: Use syringe with lidocaine and inject to anesthetize deeper structures while advancing the needle under ultrasound visualization
  5. Exchange for sheath
    • Using seldinger technique, exchange needle for sheath with corresponding wire (included in the micropuncture kit)
    • Practical tip: If serosanguinous or bloody effusion, a sample can be left in a plastic tray to check for clotting.
  6. Bubble study
    • Using 3-way stopcock attached to sheath, infuse agitated saline, and visualize with ultrasound in the same or alternate window.
  7. Drainage Catheter insertion
    • Using seldinger technique again, exchange sheath for catheter using J tip wire
    • Practical tip: skin nick and catheter dilator helps facilitate catheter insertion
  8. Drain fluid
    • Practical tip: Use syringe to drain fluid initially to achieve hemodynamic stability, send for samples and then attach to drainage system

Confirmation Tests

  • Very important to confirm placement prior to dilation and insertion of drain.
  • Dilation and insertion of the drainage catheter into the ventricle is a catastrophic complication.
  • How to confirm: (recommended to use multiple methods)
    1. Direct visualization of the needle entering the pericardial space
    2. Visualizing the guidewire in the pericardial space
    3. Agitated Saline Injection (recommended)
      • Saline is agitated using two syringes connected with a 3-way stopcock.  The agitated saline is is injected quickly into the needle or micropuncture catheter, while imaging the pericardial space with ultrasound.
    4. Clotting Test
      1. Place a small amount of pericardial fluid in a plastic container (often equipment tray).  Most pericardial fluid should not form clots and should remain liquid. 
  • Authors: Dr. Atul Jaidka, Dr. Daniel Durocher and Dr. Pavel Antiperovitch (MD, FRCPC, Cardiology Fellow)