Pericardial Effusion

I30

DESCRIPTION

Accumulation of fluid in the pericardial space, usually secondary to pericarditis.

DIAGNOSTIC CRITERIA

Clinical

  • Most patients present with a prolonged history of:
    • low cardiac output,
    • distended neck veins,
    • muffled or diminished heart sounds.
  • Patients with HIV may be asymptomatic and incidentally diagnosed on chest X-ray.
  • Often associated with TB.
  • Acute septic pericarditis may occur in patients with septicaemia.

Investigations

  • Exclude TB in all cases. Tuberculin skin test.
  • ECG:
    • small complexes tachycardia,
    • diffuse T wave changes,
  • Chest X-ray:
    • in pericardial effusion – “water bottle” large globular heart or cardiac shadow with smoothed out borders.
  • Ultrasound of heart and pericardium.
  • Diagnostic pericardiocentesis:
    • in all patients with suspected bacterial or neoplastic pericarditis, and in all others in whom the diagnosis is not readily obtained;
    • include cell count and differential, culture and gram stain;
    • an elevated adenosine deaminase (ADA) may be helpful in diagnosing TB.

CARDIAC TAMPONADE

Cardiac tamponade is the accumulation of pericardial fluid that restricts ventricular filling and stroke volume. The child usually presents with a tachycardia, pulsus paradoxus, elevated JVP, hypotension, shock or pulseless electric activity.

Features on ECG include electrical alternans and low voltage QRS. Diagnosis is confirmed by ultrasound.

GENERAL AND SUPPORTIVE MEASURES

Urgent pericardiocentesis under ultrasound guidance by an experienced person.

Pericardiocentesis

  • Do a coagulation screen if coagulation problems are suspected.
  • Preferably under ultrasound guidance by an experienced person.
  • In an emergency, drainage by using a large bore intravenous cannula.
  • Technique:
    • Ensure that full resuscitation equipment is available as well as an IV line and cardiac monitor.
    • Administer oxygen via face mask, nasal cannula or head box.
    • If the patient is restless, it may be necessary to sedate the patient. In an emergency situation, this is unnecessary.
    • Position the patient in a 30° sitting-up position.
    • Prepare the preferred site just to the left of the xiphoid process, 1 cm inferior to the costal margin.
    • Infiltrate this area with 1% lidocaine (lignocaine).
    • Maintaining negative pressure on the syringe, insert the needle at a 45° angle to the skin, advancing in the direction of the patient's left shoulder.
    • While advancing the needle, observe closely on ECG for ventricular ectopic beats, a sign of myocardial contact. If this is noted, gradually withdraw the needle a few mm.
    • Once air (pneumopericardium) or fluid begins to fill the syringe, advance the intravenous cannula, withdraw the needle, attach the syringe to the hub of the cannula and slowly aspirate the pericardial fluid.
    • Potential complications include: haemopericardium (from laceration of the heart wall or coronary artery), cardiac dysrythmias, pneumothorax, and pneumopericardium.

MEDICINE TREATMENT

If suspected or proven TB pericarditis, give antituberculosis drugs for 6 months plus corticosteroids.

  • Prednisone, oral, 6 weeks:
    • Week 1: 2 mg/kg/day,
    • Week 2: 1.5 mg/kg/day,
    • Week 3: 1 mg/kg/day,
    • Week 4: 1 mg/kg/day,
    • Week 5: 0.5 mg/kg/day,
    • Week 6: 0.25 mg/kg/day.

LoEIII [9]
LoEIII [10]

Pain management

See Management of pain .

Antibiotic therapy

If suspected bacterial pericarditis give empiric antibiotic treatment until culture and sensitivity results are available.

Antibiotic therapy should be continued for 4 weeks.

In case of purulent pericarditis:

  • Cloxacillin, IV, 50 mg/kg/dose 6 hourly.

PLUS

  • Ceftriaxone, IV, 100 mg/kg as a single daily dose.

REFERRAL

  • Refer all patients after stabilisation.