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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 3  |  Issue : 1  |  Page : 45-47

Management of entrapped intra-pericardial needle : A challenging task


1 Department of Anaesthesiology & Critical Care Medicine, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna, Bihar, India
2 Department of CTVS, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna, Bihar, India

Date of Web Publication11-Dec-2020

Correspondence Address:
Sanjeev Kumar
MBBS, MD, (BHU, Varanasi), D-5/4, IGIMS, Patna, PIN-800014 Contact No: +91-9473191829, +91-9835608714,
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 


30 year old female admitted in emergency department with complaints of difficulty in breathing. She was a known case of systemic lupus erythematosus and had undergone lower segment cesarean section 6 month back. In postpartum period she developed post partum haemorrhage leading to acute renal failure which was managed by hemodialysis. Later her echocardiography confirmed massive pericardial effusion with temponade effect. Pericardiocentesis was tried to relieve the symptoms but during this procedure the needle was broken from its base, and even an attempt of needle retrieval could not be succeeded and it was presumed that it dropped down inside pericardial sac, which was removed by exploring the thoracic cage under general anaesthesia. She stayed in the hospital ward for one week and then discharged uneventfully.

Keywords: Pericardial Effusion, Pericardiocentesis, Broken Needle, Thoracotomy, General Anaesthesia


How to cite this article:
Kumar S, Kumar R, Avneesh S, Shekhar S, Gupta A. Management of entrapped intra-pericardial needle : A challenging task. J Indira Gandhi Inst Med Sci 2017;3:45-7

How to cite this URL:
Kumar S, Kumar R, Avneesh S, Shekhar S, Gupta A. Management of entrapped intra-pericardial needle : A challenging task. J Indira Gandhi Inst Med Sci [serial online] 2017 [cited 2021 Dec 6];3:45-7. Available from: http://www.jigims.co.in/text.asp?2017/3/1/45/303129




  Introduction Top


Pericardiocentesis is a procedure usually performed with the help of a long wide bore needle to aspirate pericardial fluid from pericardial sac for therapeutic or diagnostic point of view. Initially it was done blindly which sometimes causes failed pericardiocentesis and also lead to variety of complications with high morbidity and mortality. Such complications are dramatically reduced with use of modern technology but still few complications occur due to various reasons.


  Case Report Top


30 year old female arrived in emergency department with complaints of difficulty in breathing. She was a known case of systemic lupus erythematosus and had undergone lower segment cesarean section (LSCS) 6 month back. After LSCS she developed post partum hemorrhage followed by acute kidney injury for which she was put on biweekly hemodialysis. Chest x- ray and ECG revealed cardiomegaly with bilateral pleural effusion (left side>right side) and low voltage ECG tracing. Echocardiography confirmed massive pericardial effusion with temponade, for which she underwent echcardiograρhic guided pericardiocentesis with the help of a wide long bore needle (16 G, 12 cm long), During procedure the needle was broken from its base most probably due to some manufacturing or other technical fault. An attempt of needle retrieval was done under echocardiograpic and cinefluroscopic guidance, but could not be thriven and it was presumed that it dropped down inside pericardial sac. [Figure 1] Since there was possibility that this needle may go inside cardiac chamber or great vessel hence decided for immediate emergency thoracotomy under general anaesthesia. During preanaesthetic evaluation she was conscious, oriented but had breathlessness due to presence of large amount of pleural/pericardial fluid and bilateral rhonchi. Her haemoglobin, serum sodium, serum potassium, blood urea, serum creatinine and INR were reported 6.4gm/dl, 130meq/dl, 5.4 meq/dl, 229mg/dl, 7.5mg/dl and 1.64 respectively.
Figure 1: X-ray chest showing cardiomegaly with broken needle at base.

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The patient was taken for emergency surgery under high risk consent and shifted to operating room, where her heart rate, blood pressure and SpO2 were 140/min, 180/110mm Hg and 94% respectively. Although she had still a lot of symptoms but since it was an emergency situation and any further delay may aggravate the condition, the anaesthesia team provided general anaesthesia with all due care like proper nebulization with bronchodilators, i.v. paracetamol infusion and antibiotic coverage. Her vitals like heart rate, blood pressure, EtCO2, SpO2, temperature were monitored in the operation room. In this case the analgesic inj. Fentanyl 2μg/kg was used and was anaesthetized with judicious dose of anaesthetic drugs to maintain the haemodynamics. Therefore she was induced with inj. Propofol (1.5mg/kg), inj. Vecuronium bromide (0.1mg/kg) and maintained with oxygen, nitrous oxide, isoflurane (0.4-0.8%) and intermittent dose of inj. Vecuronium bromide. During surgery left antero-lateral thoracotomy was done where massive left sided pleural effusion (approx. 1.5 liters) was present. Pericardial fluid was aspirated then pericardium was opened after taking two stav sutures, where gross (approx. 500ml) hemorrhagic fluid was found, which was suctioned. Gently the heart was lifted with left hand and needle was located with right hand. Needle was found posterior to the heart with partially puncturing the right ventricular cavity. Right ventricular surface was contused due to repeated punctures with needle in the right ventricular myocardium. The broken needle was removed delicately. [Figure 2] and [Figure 3]. Right ventricular rent was repaired with prolene 6-0 interrupted suture. Haemostasis was secured. Pericardium was left open creating a pleura-percardial window. Thoracotomy closure was done with No 5 Ethibond over intercostal tube drainage. After completion of surgery and pericardial drainage the clinical parameters of the patient had improved. Subsequently the patient was extu bated uneventfully and sent to intensive care unit with oxygen mask for further observation. She stayed in the hospital ward for one week then discharged with all required advice.
Figure 2: Intraoperative needle after exploration of thorax

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Figure 3: Needle after removal from pericardial sac

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  Discussion Top


Nowadays pericardiocentesis is common procedure done usually under ultrasound guidance by cardiologist, cardiothoracic surgeon, intensivist or interventional radiologist for the symptomatic patients suffering from pericardial effusion for diagnostic and therapeutic purposes but first time it was illustrated by Riolanus in 1653 and he had delineated the trephination of the sternum to aIleviate fiuid surrouηding the heart.[1]

In patient with massive pericardial effusions pericardiocentesis under guidance of advance sonography has high success rates (>95%) with relatively slight risk. Although reported morbidity ranges from 1-3% of cases and the mortality caused by directly from the procedural injuries is not < 1% of cases.[2] Initially there was very high morbidity by way of serious life threatening complications (>20%) leading to mortality looming to 6%.[2],[3],[4] Nevertheless, with advancement of sonologic techniques in the 1970s, pericardiocentesis has developed as a vital role in the diagnosis and management of the most of haemodynamically significant patients with pericardial effusions.[5] Now pericardiocentesis under ultrasound guidance is the standard clinical practice in the management of pericardial effusions.[6] Currently this procedure can be performed harmlessly in an outpatient setting vigilantly in the selected and stable patients and is well-tolerated in every one including children and can be carried out quickly even in the unstable patients to mitigate symptoms of pericardial tamponade.[7],[8],[9]

In spite of this several complications of pericardiocentesis are described by many authors time to time in their studies, Actis Dato et al in 2003 reported a series of 14 cases of post-traumatic or iatrogenic foreign bodies in the heart including 3 cases where needles were entered inside the left ventricle, atrium and pulmonary artery, which were managed successfully by surgical intervention.[10]

Although pericardiocentesis is frequently required for pericardial effusion secondary to malignancy and uremia but now it is more common due to tuberculosis in patients of developing countries.[11],[12] Currently due to advancement in interventional cardiology several studies showed increasing incidence of iatrogenic pericardial effusion mainly due to as complication of percutaneous intervention like coronary angioplasty, valvuloplasty, radiofrequency ablation, cardiac biopsy, diagnostic catheterization etc.,[11],[12],[13],[14],[15],[16] This problem aggravates further in patients on anticoagulant or antiplatelets therapy for existing cardiovascular problems. Therefore in such patient the European Cardiology Society has forbidden in its guideline for performing pericardiocentesis to reduce the risk of complication.[16] Another study done by Ho et al. in 2015 showed that pericardiocentesis carried out for pericardial effusion after catheter-based cardiac intervention have more acute complications compared to other reasons of pericardial effusion.[17]


  Conclusion Top


Pericardiocentesis is considered as a life-saving practice for both diagnostic and therapeutic purpose and can be reasonably safe if done under continuous monitoring of ECG and guidance of fluoroscopy and ultra-sonography/echo-cardiography. The severity of complications of pericardiocentesis depends upon its precise indication, nature, frequency and risk factors. Although complications associated with pericardiocentesis are infrequent but if occur like breaking of needle inside pericardial sac or other space etc may be exceedingly fatal if not managed timely. Usually in such cases urgent exploration of thorax is required under general anaesthesia, where anaesthetic management is dreadfully challenging due to compromised haemodynamics. Only the appropriate care in patient selection, considering the etiological factors, judicious use of anaesthetic drugs and proper peri-operative management can reduce morbidity and mortality.



 
  References Top

1.
Loukas M, Walters A, Boon JM, Welch TP, Meiring JH, Abrahams PH. Pericardiocentesis: A clinical anatomy review. Clin Anat. 2012; 25:872-81.  Back to cited text no. 1
    
2.
Nguyen CT, Lee E, Luo H, Siegel RJ. Echocardiographic guidance for diagnostic and therapeutic percutaneous procedures. Cardiovasc Diagn Ther. 2011; 1:11-36.  Back to cited text no. 2
    
3.
Ainsworth CD, Salehian O. Echo-guided pericardiocentesis: Let the bubbles show the way. Circulation. 2011;123:e210-1.  Back to cited text no. 3
    
4.
Kil UH, Jung HO, Koh YS, Park HJ, Park CS, Kim PJ, et al. Prognosis of large, symptomatic pericardial effusion treated by echo-guided percutaneous pericardiocentesis. Clin Cardiol. 2008; 31:531-7.  Back to cited text no. 4
    
5.
Maggiolini S, Bozzano A, Russo Ρ, Vitale G, Osculati G, Cantù E, et al. Echocardiography-guided pericardiocentesis with probe-mounted needle: Report of 53 cases. J Am Soc Echocardiogr. 2001; 14:821-4.  Back to cited text no. 5
    
6.
Osranek M, Bursi F, O’Leary PW, Bruce CJ, Sinak LJ, Chandrasekaran K, et al. Hand-carried ultrasound-guided pericardiocentesis and thoracentesis. J Am Soc Echocardiogr. 2003; 16:480-4.  Back to cited text no. 6
    
7.
Drummond JB, Seward JB, Tsang TS, Hayes SN, Miller FA., Jr Outpatient two-dimensional echocardiography-guided pericardiocentesis. J Am Soc Echocardiogr. 1998; 11:433-5.  Back to cited text no. 7
    
8.
Tsang TS, El-Najdawi EK, Seward JB, Hagler DJ, Freeman WK, O’Leary PW. Percutaneous echocardiographically guided pericardiocentesis in pediatric patients: Evaluation of safety and efficacy. J Am Soc Echocardiogr. 1998; 11:1072-7.  Back to cited text no. 8
    
9.
Tsang TS, Freeman WK, Barnes ME, Reeder GS, Packer DL, Seward JB. Rescue echocardiographically guided pericardiocentesis for cardiac perforation complicating catheter-based procedures. The Mayo Clinic experience. J Am Coll Cardiol. 1998; 32:1345-50.  Back to cited text no. 9
    
10.
GM Actis Dato, Arslanian A, Marzio PD,Filosso PL, Ruffini E, Post-traumatic and iatrogenic foreign bodies in the heart: Report of fourteen cases and review of the literature. The Journal of Thoracic and Cardiovascular Surgery, August 2003, Volume 126, Number- 2,408-414.  Back to cited text no. 10
    
11.
Abramov D, Tamariz MG, Fremes SE, Guru V, Borger MA, Christakis GT, et al. Trends in coronary artery bypass surgery results: A recent, 9-year study. Ann Thorac Surg. 2000;70:84- 90.  Back to cited text no. 11
    
12.
Inglis R, King AJ, Gleave M, Bradlow W, Adlam D. Pericardiocentesis in contemporary practice. J Invasive Cardiol. 2011; 23:234-9. 14. Tsang TS, Enriquez-Sarano M, Freeman WK, Barnes ME, Sinak LJ, Gersh BJ, et al. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: Clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc. 2002;77:429- 36.  Back to cited text no. 12
    
13.
Friedrich SP, Berman AD, Baim DS, Diver DJ. Myocardial perforation in the cardiac catheterization laboratory: Incidence, presentation, diagnosis, and management. Cathet Cardiovasc Diagn. 1994;32:99-107.  Back to cited text no. 13
    
14.
Baim DS, Diver DJ, Feit F, Greenberg MA, Holmes DR, Weiner BH, et al. Coronary angioplasty performed within the thrombolysis in Myocardial Infarction II study. Circulation. 1992;85:93-105.  Back to cited text no. 14
    
15.
Isner JM. Acute catastrophic complications of balloon aortic valvuloplasty. The Mansfield Scientific Aortic Valvuloplasty Registry Investigators. J Am Coll Cardiol. 1991;17:1436-44.  Back to cited text no. 15
    
16.
Gibbs CR, Watson RD, Singh SP, Lip GY. Management of pericardial effusion by drainage: A survey of 10 years’ experience in a city centre general hospital serving a multiracial population. Postgrad Med J. 2000;76:809-13.  Back to cited text no. 16
    
17.
Ho MY, Wang JL, Lin YS, Mao CT, Tsai ML, Wen MS, et al. Pericardiocentesis adverse event risk factors: A nationwide population-based cohort study. Cardiology. 2015;130:37-45.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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