Retrospective Study

Adverse events associated with pericardiocentesis

in dogs: 85 cases (1999^2006)
Karen R. Humm, MA, VetMB, DACVECC, MRCVS; Elizabeth A. Keenaghan-Clark, MA, VetMB,
MRCVS and Amanda K. Boag, MA, VetMB, DACVIM, DACVECC, FHEA, MRCVS
Abstract
Objective To quantify the frequency of adverse events occurring during or post pericardiocentesis and to
determine if adverse events are related to the cause of the pericardial effusion or frequency of
pericardiocentesis.
Design Retrospective study.
Setting Referral hospital.
Animals, Intervention and Measurements Medical records of 85 dogs that underwent 112 episodes of
pericardiocentesis were reviewed. Any adverse events during pericardiocentesis and in the 48 hours post
pericardiocentesis were noted. The frequency of adverse events was compared between dogs with a suspected
neoplastic cause and a suspected nonneoplastic cause of their pericardial effusion and also between the rst
and subsequent pericardiocenteses.
Main Results The incidence of adverse events was 10.7% within 1 hour of pericardiocentesis and 15.2%
within 48 hours. There was no signicant difference in the frequency of adverse events between the groups.
Most adverse events identied were dysrhythmias. Forty-one percent of those dogs with adverse events were
euthanized or died within 48 hours.
Conclusion The incidence of adverse events seen within 48 hours of pericardiocentesis was 15.2%.
(J Vet Emerg Crit Care 2009; 19(4): 352356) doi: 10.1111/j.1476-4431.2009.00436.x
Keywords: arrhythmia, cardiac, death, dysrhythmia, pericardial effusion
Introduction
Pericardial effusion is a well-described clinical condition
in the dog. Increasing levels of pericardial uid lead to
elevated intrapericardial pressure; if this pressure
increases to a level greater than or equal to right ven-
tricular pressure, tamponade occurs. Clinical signs con-
sistent with right-sided congestive heart failure and
decreased cardiac output result. Pericardiocentesis is the
most effective and rapid way of resolving the clinical
signs and is often performed as an emergent
procedure. Pericardial uid obtained during pericardio-
centesis may also be useful for diagnostic purposes.
15
Pericardial effusions most commonly have a neoplastic or
idiopathic etiology in the dog.
6,7
Other potential causes
include congestive heart failure,
6
hypoproteinemia,
6
per-
icardioperitoneal diaphragmatic hernia,
8
infection,
9,10
atri-
al rupture,
11
and coagulopathy.
12,13
The technique for pericardiocentesis has been well
described.
14,15
While it is often noted that complications
may occur during or following pericardiocentesis, the
frequency and nature of these complications has not
been reported previously in dogs.
14,15
A study in hu-
mans of 1127 cases of therapeutic pericardiocentesis
found a major complication (an undesirable event oc-
curring due to pericardiocentesis requiring interven-
tion) rate of 1.2% and a minor complication (events
which required no management other than appropriate
monitoring and follow up) rate of 3.5%,
16
giving a total
complication rate of 4.7%.
This retrospective study describes the frequency and
nature of adverse events occurring during or following
pericardiocentesis in dogs and evaluates whether the
frequency of these events varies between different
patient groups.
A portion of this work was presented in abstract form at the British Small
Animal Veterinary Association Congress in 2005.
Address correspondence and reprint requests to
Dr. Karen R. Humm, Department of Veterinary Clinical Sciences, The
Queen Mother Hospital for Animals, The Royal Veterinary College,
Hawkshead Lane, North Mymms, Hertfordshire AL9 7TA, UK.
Email: khumm@rvc.ac.uk
From the Department of Veterinary Clinical Sciences, The Queen Mother
Hospital for Animals, The Royal Veterinary College, Hertfordshire AL9
7TA, UK.
Journal of Veterinary Emergency and Critical Care 19(4) 2009, pp 352356
doi:10.1111/j.1476-4431.2009.00436.x
& Veterinary Emergency and Critical Care Society 2009 352
Materials and Methods
Selection of cases
Medical records of a large referral hospital (The Queen
Mother Hospital for Animals, The Royal Veterinary Col-
lege) were searched for the period January 1999 to June
2006 for all dogs that had undergone pericardiocentesis.
Patients were excluded from the study if the medical
records were unavailable or incomplete or if the peri-
cardiocentesis had not been performed at the hospital.
Procedures
The age, sex, breed, clinical examination ndings, and
echocardiographic results were recorded. ECG results
before pericardiocentesis and cytologic analysis of the
uid were also recorded if performed. If a dog subse-
quently underwent thoracotomy or necropsy, the nal
diagnosis was recorded. For patients that underwent
multiple pericardiocenteses, each episode of pericardio-
centesis was recorded and analyzed separately. Patients
were monitored closely, generally with ECGs for 24
hours post pericardiocentesis and regular physical
examination was performed. The kennel sheets and daily
summary notes of the patients were then examined for
the day of pericardiocentesis and the following 48 hours
for any adverse events. An adverse event was dened as
a deterioration in the patients condition resulting in the
need for further intervention including drug therapy or
that resulted in death or euthanasia of the patient.
The dogs were classied into 2 groups dependent on
whether they were suspected to have a neoplastic (mass
positive) or nonneoplastic (mass negative) cause of
pericardial effusion. Dogs were included in the mass
positive group if a mass was visualized on echocardio-
graphic examination, if neoplastic cells were found on
cytologic examination of the pericardial uid or if a
neoplasm was noted at surgery or on postmortem ex-
amination. All other dogs were classied as mass neg-
ative. If an animal was thought to have a mass negative
effusion and was later found to be mass positive, all
previous pericardiocentesis episodes were included in
the mass positive group. Pericardiocentesis episodes
were also classied into 2 groups dependent on
whether they represented a rst or subsequent episode.
Descriptive statistics were performed using commer-
cially available software.
a
The incidence of adverse
events was compared between the mass positive and
mass negative groups and between rst and subsequent
pericardiocentesis groups using chi-squared analysis
with a result being considered signicant if P 0.05.
a
Results
One hundred and eight cases had pericardiocentesis
performed in the period identied. Twenty-three cases
were excluded due to absent or incomplete records.
One hundred and twelve episodes of pericardiocentesis
were performed on 85 dogs. Sixty-one of the 85 dogs
(71.8%) were male (37 entire and 24 neutered) and 24
(28.2%) were female (5 entire and 19 neutered). A large
number of breeds were represented including 14 mixed
breeds (16.5%), 13 Golden Retrievers (15.3%), 12 Ger-
man Shepherd Dogs (14.1%), and 5 Labrador Retrievers
(5.9%). Other breeds were represented by 3 dogs or
fewer. The median age at time of the rst pericardio-
centesis episode was 8.5 years (range 0.912.4 y).
Physical examination before each episode of per-
icardiocentesis revealed poor pulse quality, pulsus para-
doxus, or tachycardia in 77 of 112 (68.8%) dogs. Pulse
decits or an irregular rhythmwere noted in 5 dogs and 4
of these animals had an ECG before pericardiocentesis
that detected a dysrhythmia. The fth dog was consid-
ered to have sinus arrhythmia and no ECG was per-
formed.
ECG ndings before pericardiocentesis were noted in
the records for 48 of the 112 (43%) pericardiocentesis
episodes. The most common abnormalities seen were
electrical alternans in 22 of 48 cases (45.8%), sinus
tachycardia in 16 of 48 cases (33.3%), decreased QRS
amplitude in 9 of 48 cases (18.8%) and intermittent
ventricular premature complexes in 5 of 48 cases
(10.4%). Six of the 48 (12.5%) dogs with ECG records
were within normal limits. Several cases had more than
1 ECG abnormality noted. Other abnormalities seen
were runs of ventricular tachycardia in 2 cases and
sinus arrhythmia, atrial brillation, intermittent supra-
ventricular tachycardia, and intermittent atrial prema-
ture complexes in 1 case each. One dog was treated
with lidocaine before pericardiocentesis due to frequent
ventricular premature complexes.
In 17 of 112 (15.2%) pericardiocentesis procedures an
adverse event was documented within the 48-hour pe-
riod following the procedure. Adverse events were
noted most frequently during or shortly after peri-
cardiocentesis with 11 of 17 (65%) adverse events
occurring within 1 hour. No dog had an adverse event
on more than 1 episode of pericardiocentesis.
Adverse events seen included dysrhythmias requir-
ing drug therapy in 11 of 17 (65%) cases (see Table 1),
cardiopulmonary arrest in 4 of 17 (24%) cases, and
continued bleeding into the pericardium that resulted
in euthanasia of the dog in 3 of 17 (18%) cases. One dog
had ventricular tachycardia requiring lidocaine therapy
at the time of pericardiocentesis and also underwent
cardiopulmonary arrest 13 hours later. Of the dogs un-
dergoing cardiopulmonary arrest, the arrest occurred at
1, 2, 13, and 26 hours post pericardiocentesis. Three
dogs underwent cardiopulmonary arrest of unknown
cause and 1 was seen to proceed rapidly from ventric-
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00436.x 353
Adverse events associated with pericardiocentesis
ular tachycardia, to ventricular brillation, to asystole.
Three dogs were euthanized due to continued
bleeding into the pericardium. Continued bleeding
was visualized by echocardiography immediately post
pericardiocentesis in 1 case and in the other 2 cases
PCVand total solids values were noted to decrease over
a 24-hour period resulting in the presumption of con-
tinued bleeding. All of these dogs had a concurrent
deterioration in their clinical status. Two were mass
positive and the third was coagulopathic with elevated
prothrombin and partial thromboplastin times.
Eight of the 17 dogs that had adverse events had ECG
results before pericardiocentesis noted in their medical
records. Three of those dogs had dysrhythmias noted
and went on to have dysrhythmic adverse events.
One had a worsening of a supraventricular tachycardia
with the development of novel ventricular premature
complexes, 1 developed atrial brillation with the
previous abnormality noted being intermittent ventric-
ular premature complexes, and 1 developed ventricular
tachycardia with intermittent ventricular premature
complexes noted before pericardiocentesis. Five dogs
having adverse events did not have a dysrhythmia
noted on their ECG before pericardiocentesis. Three of
these dogs developed a dysrhythmia (all were ventric-
ular tachycardia), 1 underwent a cardiopulmonary ar-
rest of unknown cause and 1 was suspected to have
continued bleeding. Nine of the 17 dogs (53%) with
adverse events post pericardiocentesis were discharged
from the hospital compared with 56 of 68 dogs (82%)
that did not experience an adverse event.
Sixty-four of 112 (57.1%) pericardiocentesis episodes
were performed on mass negative effusions and 48 of
112 (42.9%) episodes on mass positive effusions. Of
those classied as mass positive, 27 of 36 (75%) were
diagnosed with echocardiography, 7 of 36 (19.4%) were
diagnosed at surgery or with the aid of surgical biop-
sies, and 2 were diagnosed with cytologic analysis of
uid. There was no signicant difference in the fre-
quency of adverse events between these 2 groups
(P50.52). Eighty-ve of the 112 (75.9%) procedures
were rst time episodes and 27 of 112 (24.1%) were
second or subsequent episodes (25 animals had a sec-
ond pericardiocentesis and 2 had a third). There was no
signicant difference in the frequency of adverse events
dependent on whether the pericardiocentesis was a rst
or subsequent procedure (P50.33).
Discussion
The population of dogs reported here as undergoing
pericardiocentesis is similar to previously reported
populations of dogs presenting for pericardial effusion.
Forty-two percent of dogs in the study were suspected
to have a neoplastic cause for their pericardial effusion.
Pericardial effusions have been shown to have a neo-
plastic etiology in 3168% of dogs.
2,3,7,17
The breeds that
appear with high frequency in this study (German
Shepherd Dogs, Golden Retrievers, and Labrador
Retrievers) are similar to those reported to be at risk
in previous studies.
6,7,17
The mean age of the dogs is
similar to previous studies; mean age ranges between
6.8 and 9.1 years.
6,17,18
The rate of complications during or following peri-
cardiocentesis has not been reported previously in
dogs. We chose to use the term adverse events as op-
posed to complications as it is not possible to know
whether the events occurred as a result of the proce-
dure itself or secondary to the underlying disease. The
adverse event rate of 15% is greater than the compli-
cation rate of 4.7% reported in a human study.
16
Inter-
estingly, only 3 cases of dysrhythmia were noted in the
human study (0.27% overall), whereas these constituted
the majority of adverse events reported here. In hu-
mans, the most commonly noted complications were
pneumothoraces (some minor and some requiring chest
tube placement). Small pneumothoraces may not have
been noted in our patient population as radiography
post pericardiocentesis is not performed routinely. The
difference in the frequency of dysrhythmias seen may
be due to the fact that pericardiocentesis in humans is
usually guided by imaging modalities such as echocar-
diography or computerized tomography whereas in
Table1: Dysrhythmias seen post pericardiocentesis requiring
drug therapy
Dysrhythmia
Number
of cases Treatment
Ventricular tachycardia
n
8 Lidocaine (n 58)w
Procainamide (n 52)z
Magnesium (n 51)
Sotalol (n 51)z
Mexilitine (n 51)k
Atrial brillation 1 Benazapril
nn
and Digoxinww
Atrial premature complexes 1 Atenololzz
Supraventricular tachycardia 1 Diltiazem
n
All dogs were treated with lidocaine. One dog was also treated with
procainamide and magnesium, another with sotalol and mexilitine, and
another with procainamide.
wLidocaine, B Braun Medical Ltd, Shefeld, UK.
zPronestyl, Squibb Bristol-Myers Pharmaceuticals Ltd, Dublin, Ireland.
Magniject 9, Norbrook Laboratories Ltd, Newry, UK.
zSotacor, Bristol Myers Pharmaceuticals, Hounslow, UK.
k Mexitil, Boehringer Ingelheim, Bracknell, UK.
nn
Fortekor, Novartis, Waterford, Ireland.
wwLanoxin, GlaxoSmithKline UK, Uxbridge, UK.
zzAtenolol, Bristol Laboratories Ltd, Berkhampstead, UK.
Diltiazem, Hospira, Lake Forest, IL.
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00436.x 354
K.R. Humm et al.
dogs it is more commonly a blind procedure leading to
increased likelihood of contact with the epicardium and
possibly increased likelihood of dysrhythmia.
14,16,19
Alternatively, the canine heart with a pericardial effu-
sion may be more prone to dysrhythmias due to species
differences, or perhaps due to the difference in under-
lying cause of the effusion. The underlying cause of
pericardial effusions does vary between humans and
dogs with a large study of 1,127 human patients show-
ing that effusions requiring pericardiocentesis were
most commonly due to malignancy (33.3%) or were
postoperative (24.6%) although 8.0% were idiopathic.
16
It is possible that hypovolemia and myocardial hypoxia
are more common in dogs due to the increased prev-
alence of bleeding neoplasms and that this may result
in dysrythmias. Neoplastic cardiac tissue may also be
more vulnerable to dysrhythmias secondary to reper-
fusion once the pericardial effusion has been drained.
No relationship was found between the cause of the
pericardial effusion and the likelihood of adverse
events in this study, however.
Ultrasound guidance was not used during peri-
cardiocentesis in this study, although frequently it
was used before the procedure to guide the needle or
catheter insertion point. The use of ultrasound guid-
ance during the procedure could decrease the likeli-
hood of adverse events by decreasing the likelihood of
epicardial contact. However, needle placement under
ultrasound guidance can be technically challenging and
the veterinarians performing pericardiocentesis in this
study had varying levels of expertise.
Dysrhythmias (other than sinus arrhythmia) were
noted in 8.9% of patients before pericardiocentesis.
Although prepericardiocentesis ECG ndings were
documented for only 43% of patients, the authors sug-
gest that it is unlikely that a much higher proportion of
patients had clinically signicant dysrhythmias requir-
ing specic treatment on presentation as these are likely
to have been noted on a physical examination. Further,
we also believe that it is possible that a higher number
of patients had a prepericardiocentesis ECG performed
but that unremarkable ndings may not have been
documented in the record. A previous study docu-
mented dysrhythmias in 26% of dogs in which an ECG
was taken before pericardiocentesis though it was not
noted why this subpopulation of dogs underwent ECG
assessment.
6
It is possible they were selected due to
suspicion of dysrhythmia suggesting that this level of
dysrhythmia may not be representative of all dogs with
pericardial effusion.
6
Dysrhythmias either during or
post pericardiocentesis were not reported in this study.
6
Dysrhythmias were only classed as adverse events if
they required drug therapy or resulted in the death or
euthanasia of the patient. The clinical decision as to
whether a dysrhythmia warrants drug treatment is
subjective possibly leading to variation between clini-
cians, although standard criteria are used to aid deci-
sion making.
20
Considering the retrospective nature of
this study, the decision to treat was considered to pro-
vide the best available marker for the severity of
dysrhythmia seen. When clinically insignicant rhythm
abnormalities such as occasional ventricular premature
complexes were noted post pericardiocentesis they
were not classed as an adverse event. Future prospec-
tive studies would be required to dene more precisely
the severity of dysrhythmias seen.
Of the 4 dogs that died suddenly during the 48 hours
post pericardiocentesis, the cause of death was only
clearly documented in 1, which was seen on ECG to
progress from ventricular tachycardia to ventricular -
brillation and death. Although it is possible that the
others suffered a fatal dysrhythmia, ECG ndings
were not recorded immediately precardiopulmonary ar-
rest. One of these dogs had been noted to have intermit-
tent ventricular premature complexes immediately post
pericardiocentesis. Placement of an ECG is routine post
pericardiocentesis at the hospital in this study and is
generally continued for 24 hours or longer if a
dysrhythmia is noted. However, they can be difcult to
maintain in some patients and if not observed at the
moment of arrest then the preceding rhythm is unknown.
Other than dysrhythmias and sudden death, ongoing
bleeding into the pericardium resulting in the decision
to euthanize occurred in 3 dogs. It is possible the
bleeding was a direct result of the pericardiocentesis
although there was no information in the records to
suggest that the clinician was aware of a problem at the
time they were performing the procedure. If inadver-
tent cardiac puncture or laceration of a coronary vessel
had occurred during pericardiocentesis, dysrhythmias
can be induced
14
and none were documented in these
cases. It is also possible that alleviation of the pressure
within the pericardium post pericardiocentesis allowed
further bleeding to occur. All 3 dogs had evidence of a
mass. This ongoing bleeding was severe enough to
cause deterioration in the animals clinical status lead-
ing to the decision to euthanize.
The retrospective nature of this study means that the
management of the cases was neither controlled nor
uniform. Ideally this study should be repeated in a
prospective fashion with all dogs having ECG analysis
before pericardiocentesis, have pericardiocentesis per-
formed in a standardized fashion by a small group of
clinicians and with a set protocol for the decision of
when to treat a dysrhythmia.
This study did not nd any relationship between ei-
ther frequency of pericardiocentesis, or the underlying
cause of pericardial effusion, and the risk of adverse
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00436.x 355
Adverse events associated with pericardiocentesis
events. However, due to the numbers involved, all ad-
verse events were evaluated as 1 group as opposed to
being separated (eg, dysrhythmias and ongoing bleed-
ing). It is possible that larger numbers may reveal an
association that is currently unidentied. The number of
animals requiring multiple pericardiocenteses was also
small meaning a weak relationship may not have been
identied. A prospective study with larger numbers of
cases would help to investigate these areas further.
Pericardiocentesis is usually an emergent procedure
performed solely for therapeutic purposes and to re-
verse serious cardiovascular compromise.
14
The knowl-
edge that adverse events may occur should not prevent
the use of pericardiocentesis. This study has shown that
adverse events occur at a level of 15% following peri-
cardiocentesis. This can be communicated to the client
to aid their understanding of potential problems that
may occur after this essential procedure. As most of the
adverse events seen were dysrhythmias we would rec-
ommend that continuous ECG is performed during
pericardiocentesis and for at least 24 hours afterwards
as the risk of dysrhythmia and sudden death was most
marked during this period.
Footnote
a
GraphPad Software, San Diego, CA.
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