I now get to indulge in one of my favorite pastimes, pointing out when I did something silly. I was reminded of this by some of my wonderful nurse colleagues, who drew a parallel with a prior post of mine, the Lifesaving Foley (which I tried to make up for with this one).
The setup: a patient with a symptomatic pericardial effusion, hypotensive but hanging in there, and the thoracic surgeon is coming to see why they’ve re accumulated an effusion, as the patient just had a pericardial window about 6 days ago.
(For those not ‘in the business’ the pericardium is a tough fibrous sack which surrounds the heart. It’s one of those parts of the body you never hear about until it becomes a problem. In the case of a pericardial effusion, the problem becomes the relative stiffness of the pericardium; add fluid around the heart, the pericardium doesn’t give way, so the volume loss is up to the heart to deal with. This means the heart fills with less blood, and has to cope with less filling volumes and pressure; want to keep up the same circulation volume with a smaller output, the heart has to deliver more beats. This works for a while, but it’s the low-pressure right heart that loses out ultimately; when the pressure inside the pericardium exceeds the returning venous pressure, it’s a vapor lock. No blood goes in, so none goes out. You can see the problem.)
The intensivist feels it’s time to intubate the patient, and says ‘if [the patient] crashes, we’re going to need to drain the effusion”, and gets no argument from me. Of course, you know what happens next.
The patient has an uneventful intubation, but the addition of positive-pressure ventilation results in PEA (pulseless electrical activity). Of course the big spinal needles typically described for the needle aspiration of a pericardial effusion are nowhere to be found, but there’s a nice substitute in every resus bay: the introducer needle for a central line. So, using that needle I start the pericardiocentesis.
Needle pericardiocentesis in the ED has been described several ways, but the end result has the end of the needle inside the pericardium but outside the heart. I’ve done it before, and it’s either a very satisfying minute wherein a volume of blood is released and the patient gets immediately and gratifyingly better, or, not. My preferred approach is a subxyphoid (under the bottom of the sternum) approach, trying to visualize where the tip of the left scapula would be (if you could see through people), and aiming the needle there, pulling back on the end of the syringe while advancing.
All in the room were surprised when, instead of blood, we got back a thin, milky-white fluid, and a lot of it. My first thought, given a very recent surgery, was infection, and I then blurted out the signature line of this post: “Get me culture stick!” This while I’ve got a needle next to the heart and CPR is ongoing. (In a tribute to the professionalism of the staff, I got the culture stick in less than 30 seconds).
After looking at the fluid pouring from the needle we decided it wasn’t infectious, but was, rather, chylous, opening a whole other bag of worms (a possible injury to the thoracic duct somewhere). The chest surgeon made an appearance, used our disposable suture scissors to re-open the surgical incision, and put gushed the end of the fluid. The patient, of course, had a full recovery of pulse and blood pressure, and went off to the OR for another drain, and to see if the source of the chyle could be found.
So, beloved nurses, it goes both ways: you get your Lifesaving Foleys, and I get my Lifesaving Culture Sticks