Davis's Lab & Diagnostic Tests
Pericardial Fluid Analysis
General
Synonym/Acronym:
N/A
Rationale
To evaluate and classify the type of fluid between the pericardium membranes to assist with diagnosis of infection or fluid balance disorder.
Patient Preparation
There are no activity restrictions unless by medical direction. Note that food and fluids should be restricted for 6 to 8 hr before the procedure, as directed by the health-care provider (HCP), unless the procedure is performed in an emergency situation to correct pericarditis.
Regarding the patient’s risk for bleeding, the patient should be instructed to avoid taking natural products and medications with known anticoagulant, antiplatelet, or thrombolytic properties or to reduce dosage, as ordered, prior to the procedure. Number of days to withhold medication is dependent on the type of anticoagulant. Note the last time and dose of medication taken. Protocols may vary among facilities.
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 Fluid | Reference Value |
|---|---|
| Appearance | Clear |
| Color | Pale yellow |
| Glucose | Parallels serum values |
| Red blood cell (RBC) count | None seen |
| White blood cell (WBC) count | Less than 300 cells/microL |
| Culture | No growth |
| Gram stain | No organisms seen |
| Cytology | No abnormal cells seen |
Critical Findings and Potential Interventions
- Positive culture findings in any sterile body fluid.
Timely notification to the requesting HCP of any critical findings and related symptoms is a role expectation of the professional nurse. A listing of these findings varies among facilities.
Overview
(Study type: Body fluid [pericardial fluid] 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; fluid in a clear container for cytology; related body system: Circulatory and Immune systems. Ensure that there is an equal amount of fixative and fluid in the container for cytology.)
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.
| Characteristic | Transudate | Exudate |
|---|---|---|
| Appearance | Clear to pale yellow | Cloudy, bloody, or turbid |
| Specific gravity | Less than 1.015 | Greater than 1.015 |
| Total protein | Less than 2.5 g/dL | Greater than 3 g/dL |
| Fluid protein–to–serum protein ratio | Less than 0.5 | Greater than 0.5 |
| Fluid cholesterol | Less than 55 mg/dL | Greater than 55 mg/dL |
| WBC count | Less than 100 cells/microL | Greater than 1,000 cells/microL |
Indications
- Evaluate effusion of unknown etiology.
- Investigate suspected hemorrhage, immune disease, malignancy, or infection.
- Therapeutic application: to provide relief from cardiac tamponade (fluid buildup around the heart) by removing blood or fluid.
Interfering Factors
Factors that may alter the results of the study
- Bloody fluid may be the result of a traumatic tap.
Other Considerations:
- 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.
Potential Medical Diagnosis: Clinical Significance of Results
Increased in
Condition/Test Showing Increased Result
- Bacterial pericarditis (RBC count, 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 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)
Nursing Implications, Nursing Process, Clinical Judgement
Before the Study: Planning and Implementation
Teaching the Patient What to Expect
- Discuss how this procedure can assist with evaluating fluid around the heart.
- Explain that this procedure takes about 20 to 60 min.
- Explain that a pericardial fluid sample is needed for the test.
- Review the procedure with the patient.
- Explain that prior to the procedure, laboratory testing may be required to determine the possibility of bleeding risk (coagulation testing).
- Discuss how there may be moments of discomfort or pain when the IV line or catheter is inserted, allowing for infusion of fluids such as saline, anesthetics, sedatives, medications used in the procedure, or emergency medications.
- A sedative, local anesthetics, and/or analgesia will be administered to promote relaxation and reduce discomfort prior to needle insertion through the chest wall into the pericardium.
- Discuss how reducing health-care-associated infections is an important patient safety goal, and a number of different safety practices will be implemented during the procedure.
- Explain that hair in the area near the catheter insertion site may be clipped and the area cleaned with an antiseptic solution to cleanse bacteria from the skin in order to reduce the risk for infection.
Procedural Information
- Note: The World Health Organization, Centers for Disease Control and Prevention, and Association of periOperative Registered Nurses recommend that hair not be removed at all unless it interferes with the incision site or other aspects of the procedure because hair removal by any means is associated with increased infection rates.
- Hair removal requires facilities to use a protocol that is based on scientific literature or the endorsement of a professional organization.
- Clipping immediately before the procedure and in a location outside the procedure area is preferred to shaving with a razor.
- Shaving creates a break in skin integrity and provides a way for bacteria on the skin to enter the incision site.
- Baseline vital signs are recorded and monitored throughout the procedure.
- Positioning for this procedure is in a comfortable supine position with the head elevated 45 to 60 degrees.
- Prior to the administration of local anesthesia, the site is cleansed with an antiseptic solution and draped with sterile towels.
- The electrocardiogram is monitored for needle-tip positioning to indicate accidental puncture of the right atrium.
- A cardiac needle is inserted just below and to the left of the breastbone, and fluid is removed.
- Vital signs are monitored every 15 min for signs of hypovolemia or shock.
- Once the procedure is completed, the needle is withdrawn, and slight pressure is applied to the site along with a sterile dressing.
- Samples are placed in properly labeled specimen containers and promptly transported to the laboratory for processing and analysis.
Potential Nursing Actions
Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.
Safety Considerations
- Anticoagulants, aspirin, and other salicylates should be discontinued by medical direction for the appropriate number of days prior to a procedure in which bleeding is a potential complication.
After the Study: Implementation & Evaluation Potential Nursing Actions
Avoiding Complications
- Monitor the patient for complications related to the procedure.
- Establishing an IV site and performing a pericardiocentesis are invasive procedures. For additional information see Appendix A, subsection: Potential Contraindications and Complications Associated With Diagnostic Procedures.
- Explain the importance of immediately reporting an elevated WBC count, fever, malaise, or tachycardia (indications of infection).
- Observe/assess the needle insertion site for bleeding, drainage, inflammation, or hematoma formation.
Treatment Considerations
- Follow postprocedure vital sign and assessment protocol.
- Resume the usual diet and medications, as directed by the HCP.
- Inform the patient that 1 hr or more of bedrest is required after the procedure.
- Observe 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.
- Observe for nausea and pain. Administer antiemetic and analgesic medications as needed and as directed by the HCP.
- Administer ordered antibiotics and explain the importance of completing the entire course of antibiotic therapy even if no symptoms are present.
Clinical Judgement
- Consider what barriers exist toward completing this procedure (fear of needles, pain, difficulty breathing) and how to best overcome them.
Followup Evaluation and Desired Outcomes
- Understands that further testing, along with a referral to another HCP, may be necessary to manage the disease process and monitor the effectiveness of therapeutic interventions.
