Pericardial Fluid Analysis

Pericardial Fluid Analysis

Synonym/acronym: None.

Common use

To evaluate and classify the type of fluid between the pericardium membranes to assist with diagnosis of infection or fluid balance disorder.

Specimen

Pericardial fluid (5 mL) collected in a red- or green-top (heparin) tube for glucose, a lavender-top (EDTA) tube for cell count, and sterile containers for microbiology specimens; 200 to 500 mL of fluid in a clear container for cytology. Ensure that there is an equal amount of fixative and fluid in the container for cytology.

Normal findings

(Method: Spectrophotometry for glucose; automated or manual cell count, macroscopic examination of cultured organisms, and microscopic examination of specimen for microbiology and cytology; microscopic examination of cultured microorganisms)
Pericardial FluidReference Value
AppearanceClear
ColorPale yellow
GlucoseParallels serum values
Red blood cell countNone seen
White blood cell countLess than 300/microL
CultureNo growth
Gram stainNo organisms seen
CytologyNo abnormal cells seen

Description

The heart is located within a protective membrane called the pericardium. The fluid between the pericardial membranes is called serous fluid. Normally only a small amount of fluid is present because the rates of fluid production and absorption are about the same. Many abnormal conditions can result in the buildup of fluid within the pericardium. Specific tests are usually ordered in addition to a common battery of tests used to distinguish a transudate from an exudate. Transudates are effusions that form as a result of a systemic disorder that disrupts the regulation of fluid balance, such as a suspected perforation. Exudates are caused by conditions involving the tissue of the membrane itself, such as an infection or malignancy. Fluid is withdrawn from the pericardium by needle aspiration and tested as listed in the previous and following tables.
CharacteristicTransudateExudate
AppearanceClearCloudy or turbid
Specific gravityLess than 1.015Greater than 1.015
Total proteinLess than 2.5 g/dLGreater than 3 g/dL
Fluid-to-serum protein ratioLess than 0.5Greater than 0.5
LDHParallels serum valueLess than 200 units/L
Fluid-to-serum LDH ratioLess than 0.6Greater than 0.6
Fluid cholesterolLess than 55 mg/dLGreater than 55 mg/dL
White blood cell countLess than 100/microL Greater than 1,000/microL
LDH = lactate dehydrogenase.

This procedure is contraindicated for

    N/A

Indications

  • Evaluate effusion of unknown etiology
  • Investigate suspected hemorrhage, immune disease, malignancy, or infection

Potential diagnosis

Increased in

    Condition/Test Showing Increased Result

  • Bacterial pericarditis (red blood cell [RBC] count, white blood cell [WBC] count with a predominance of neutrophils)
  • Hemorrhagic pericarditis (RBC count, WBC count)
  • Malignancy (RBC count, abnormal cytology)
  • Post–myocardial infarction syndrome, also called Dressler’s syndrome (RBC count, WBC count with a predominance of neutrophils)
  • Rheumatoid disease or systemic lupus erythematosus (SLE) (RBC count, WBC count)
  • Tuberculous or fungal pericarditis (RBC count, WBC count with a predominance of lymphocytes)
  • Viral pericarditis (RBC count, WBC count with a predominance of neutrophils)

Decreased in

    Condition/Test Showing Decreased Result

    Bacterial pericarditis (glucose) Malignancy (glucose) Rheumatoid disease or SLE (glucose)

Critical findings

  • Positive culture findings in any sterile body fluid.

  • Note and immediately report to the health-care provider (HCP) positive culture results, if ordered, and related symptoms.

  • It is essential that a critical finding be communicated immediately to the requesting health-care provider (HCP). A listing of these findings varies among facilities.

  • Timely notification of a critical finding for lab or diagnostic studies is a role expectation of the professional nurse. Notification processes will vary among facilities. Upon receipt of the critical value the information should be read back to the caller to verify accuracy. Most policies require immediate notification of the primary HCP, Hospitalist, or on-call HCP. Reported information includes the patient’s name, unique identifiers, critical value, name of the person giving the report, and name of the person receiving the report. Documentation of notification should be made in the medical record with the name of the HCP notified, time and date of notification, and any orders received. Any delay in a timely report of a critical finding may require completion of a notification form with review by Risk Management.

Interfering factors

  • Bloody fluid may be the result of a traumatic tap.
  • Unknown hyperglycemia or hypoglycemia may be misleading in the comparison of fluid and serum glucose levels. Therefore, it is advisable to collect comparative serum samples a few hours before performing pericardiocentesis.
  • Failure to follow dietary restrictions before the procedure may cause the procedure to be canceled or repeated.

Nursing Implications and Procedure

Pretest

  • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
  • Patient Teaching: Inform the patient this procedure can assist with evaluating fluid around the heart.
  • Obtain a history of the patient’s complaints, including a list of known allergens, especially allergies or sensitivities to latex.
  • Obtain a history of the patient’s cardiovascular and immune system, especially any bleeding disorders and other symptoms, as well as results of previously performed laboratory tests and diagnostic and surgical procedures.
  • Note any recent procedures that can interfere with test results.
  • Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
  • Obtain a list of the patient’s current medications, including anticoagulants, aspirin and other salicylates, herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus). Such products should be discontinued by medical direction for the appropriate number of days prior to the surgical procedure.
  • Review the procedure with the patient. Inform the patient that it may be necessary to remove hair from the site before the procedure. Address concerns about pain and explain that a sedative and/or analgesia will be administered to promote relaxation and reduce discomfort prior to needle insertion through the chest wall. Explain that any discomfort with the needle insertion will be minimized with local anesthetics and systemic analgesics. Explain that the anesthetic injection may cause a stinging sensation. Explain that after the skin has been anesthetized, a large needle will be inserted through the chest to obtain the fluid. Inform the patient that specimen collection is performed by an HCP specializing in this procedure and usually takes approximately 30 min to complete.
  • Explain that an IV line will be inserted to allow infusion of IV fluids, antibiotics, anesthetics, and analgesics.
  • Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
  • Note that food and fluids should be restricted for 6 to 8 hr before the procedure, as directed by the HCP, unless the procedure is performed in an emergency situation to correct pericarditis. The requesting HCP may request that anticoagulants and aspirin be withheld. The number of days to withhold medication is dependent on the type of anticoagulant. Protocols may vary among facilities.
  • Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

Intratest

  • Potential complications:
  • Pain, bleeding, swelling, infection, injury to the surrounding organs

  • Ensure that the patient has complied with dietary and fluids restrictions; assure that food and fluids have been restricted for at least 6 to 8 hr prior to the procedure.
  • Ensure that anticoagulant therapy has been withheld for the appropriate number of days prior to the procedure. Notify the HCP if patient anticoagulant therapy has not been withheld.
  • Have emergency equipment readily available.
  • Have the patient void before the procedure.
  • Have the patient remove clothes above the waist and put on a gown.
  • Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
  • Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement during the local anesthetic and the procedure.
  • Record baseline vital signs, and continue to monitor throughout the procedure. Protocols may vary among facilities.
  • Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient, and label the appropriate specimen container with the corresponding patient demographics, initials of the person collecting the specimen, date and time of collection, and site location.
  • Establish an IV line to allow infusion of IV fluids, anesthetics, analgesics, or IV sedation.
  • Assist the patient into a comfortable supine position with the head elevated 45° to 60°.
  • Clip hair from the site as needed, cleanse the site with an antiseptic solution, and drape the area with sterile towels prior to the administration of local anesthesia. The skin at the injection site is then anesthetized.
  • The precordial (V) cardiac lead wire is attached to the cardiac needle with an alligator clip. The cardiac needle is inserted just below and to the left of the breastbone, and fluid is removed.
  • Monitor vital signs every 15 min for signs of hypovolemia or shock. Monitor electrocardiogram for needle-tip positioning to indicate accidental puncture of the right atrium.
  • The needle is withdrawn, and slight pressure is applied to the site. Apply a sterile dressing to the site.
  • Monitor the patient for complications related to the procedure (e.g., allergic reaction, anaphylaxis).
  • Place samples in properly labeled specimen containers, and promptly transport the specimens to the laboratory for processing and analysis.

Post-Test

  • Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
  • Instruct the patient to resume usual diet and medications, as directed by the HCP.
  • Monitor vital signs and cardiac status every 15 min for the first hour, every 30 min for the next 2 hr, every hr for the next 4 hr, and every 4 hr for the next 24 hr. Take the patient’s temperature every 4 hr for 24 hr. Monitor intake and output for 24 hr. Notify the HCP if temperature is elevated. Protocols may vary among facilities.
  • Observe/assess the patient for signs of respiratory and cardiac distress, such as shortness of breath, cyanosis, or rapid pulse.
  • Continue IV fluids until vital signs are stable and the patient can resume fluid intake independently.
  • Inform the patient that 1 hr or more of bed rest is required after the procedure.
  • Observe/assess the puncture site for bleeding or drainage and signs of inflammation each time vital signs are taken and daily thereafter for several days. Report to HCP if bleeding is present.
  • Observe/assess for nausea and pain. Administer antiemetic and analgesic medications as needed and as directed by the HCP.
  • Administer antibiotics, as ordered, and instruct the patient in the importance of completing the entire course of antibiotic therapy even if no symptoms are present.
  • Recognize anxiety related to test results, and offer support. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate. Educate the patient regarding access to counseling services, if appropriate.
  • Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Answer any questions or address any concerns voiced by the patient or family.
  • Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

  • Related tests include AST, atrial natriuretic peptide, blood gases, B-type natriuretic peptide, cancer antigens, chest x-ray, CBC WBC count and differential, CK and isoenzymes, culture and smear mycobacteria, culture blood, culture fungal, culture viral, ECG, echocardiography, α1-fetoprotein, homocysteine, LDH and isoenzymes, magnesium, MRI chest, MI scan, myoglobin, and troponin.
  • Refer to the Cardiovascular and Immune systems tables at the end of the book for related tests by body system.
References in periodicals archive ?
Pleural fluid and pericardial fluid analysis showed features of exudative effusion and culture grew Burkholderia pseudomallei; however, blood culture was negative.
Pericardial fluid analysis was done for appearance, glucose and protein content, white blood cell count, cytology and cultures ( acterial, tuberculous, fungal).
The diagnosis of a viral etiology was based on negative history of contact with tuberculosis patient, negative Montouxe test, predominant lymphocytes in blood counts, pericardial fluid analysis and negative bacterial and mycobacterial cultures of the pericardial fluid.