After starting continuous electrocardiogram (ECG) monitoring and administering a local anesthetic at the puncture site, the physician inserts the aspiration needle in one of three areas. He’ll probably choose the xiphocostal approach, with needle insertion in the angle between the left costal margin and the xiphoid process, to avoid needle contact with the pleura and the coronary vessels and thus decrease the risk of damage to these structures.

As an alternative, he may use the parasternal approach, inserting the needle into the fifth or sixth intercostal space next to the left side of the sternum, where the pericardium normally isn’t covered by lung tissue; however, this method poses a risk of puncture of the left anterior descending coronary artery or the internal mammary artery.

He may opt for a third method, the apical approach, in which he inserts the needle at the cardiac apex; however, because this method poses the greatest risk of complications, such as pneumothorax, he needs to proceed cautiously.

After inserting the needle tip, the physician slowly advances it into the pericardial sac to a depth of 1″ to 2″(2.5 to 5 cm) or until he can aspirate fluid. He then clamps a hemostat to the needle at the chest wall to prevent needle movement.

The physician aspirates pericardial fluid slowly. If he finds large amounts of fluid, he may place an indwelling catheter into the pericardial sac to allow continuous slow drainage. After the physician has removed the fluid, he withdraws the needle and places a dressing over the puncture site.