bubble contrast technique during pericadiocentesis

 Q: How the bubble contrast technique can be applied during pericadiocentesis?

Answer: Bubble contrast study helps in confirming proper needle placement during pericardiocentesis. It is a very vital adjuvant technique to add if procedure is performed emergent at the beside. It helps to confirm no accidental myocardial penetration.

Agitated saline bubble contrast is prepared by rapidly mixing 9 mL of saline with 1 mL of air between two syringes, connected via a three-way stopcock, immediately before injection. Placement of a bedside ultrasound probe is needed while bubble contrast is injected. The layering of contrast outside the heart confirms pericardial localization. If there is a rapid contrast washout or intracardiac swirling varying with the patient's cardiac output, implies probable myocardial perforation. 

Another related technique is to pass smaller diameter guidewire through the needle. It's visualization in pericardium space also implies a safe placement of the needle.

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References:

1. Ainsworth CD, Salehian O. Echo-guided pericardiocentesis: let the bubbles show the way. Circulation 2011; 123:e210.

2. Osman A, Wan Chuan T, Ab Rahman J, et al. Ultrasound-guided pericardiocentesis: a novel parasternal approach. Eur J Emerg Med 2018; 25:322. 

3. Vayre F, Lardoux H, Pezzano M, et al. Subxiphoid pericardiocentesis guided by contrast two-dimensional echocardiography in cardiac tamponade: experience of 110 consecutive patients. Eur J Echocardiogr 2000; 1:66. 

4.  Weisse AB, Desai RR, Rajihah G, Lopez S. Contrast echocardiography as an adjunct in hemorrhagic or complicated pericardiocentesis. Am Heart J 1996; 131:822.