- Occurs when fluid or clots accumulate rapidly in the pericardial space, decreasing pericardial compliance; a large amount of pericardial fluid can accumulate over an extended period of time without causing tamponade
- Ventricular compliance is decreased, leading to decreased diastolic filling and decreased stroke volume
- Systemic venous return is impaired and as RA and RV collapse occurs, blood accumulates in the venous circulation, which further decreases cardiac output and venous return
- In the extreme, pressures equalize in all heart cavities, with no blood flow
- Compensatory mechanisms:
- Tachycardia to maintain cardiac output
- Increased vascular resistance to maintain BP
- Spontaneous ventilation, by decreasing intrathoracic pressure on inspiration, facilitates RV filling and ejection
- Three phases of hemodynamic changes
- Phase I: Increased stiffness of ventricle due to pericardial fluid accumulation, requiring a higher filling pressure (LV and RV filling pressures >intrapericardial pressure)
- Phase II: Pericardial pressure increases above ventricular filling pressure, resulting in decreased cardiac output
- Phase III: Cardiac output decreases even more because of equilibration of pericardial and LV filling pressures
- Medical emergency, needs to be treated immediately to avoid death
- Any acute hemodynamic deterioration in a patient post cardiac surgery should lead to an emergent re-exploration, unless another obvious cause is present
- Dyspnea, tachypnea; patient typically sitting
- Peripheral hypoperfusion with oliguria
- Pulsus paradoxus, with decreased pulse amplitude on inspiration
- Beck’s triad: increased jugular venous pressure, hypotension, and diminished heart sounds
Echocardiogram: best diagnostic tool.
- There can be a circumferential fluid collection, or sometimes a single clot compressing the RA
- Right heart compression
- Interventricular septum flattening (RV impairing LV filling)
CXR: cardiomegaly, water-bottle-shaped heart, or pericardial calcifications; often normal 12-lead EKG findings suggestive of pericardial tamponade:
- Sinus tachycardia
- Low-voltage QRS complexes
- Electrical alternans (very specific but rare)
- PR depression in all leads
If the patient has a pulmonary artery catheter (PAC) (no indication to insert a PAC emergently)
- Low CO
- Equalization of CVP = RVEDP = PAP (diastolic)
- Hemodynamic collapse
- Emergent drainage at the bedside, ideally ultrasound-guided needle drainage (usually removing 100–200 mL of fluid is sufficient to relieve hemodynamic signs and symptoms)
- Sternotomy re-exploration at bedside if post cardiac surgery
- If less critically ill, or after emergent drainage, a pericardial window or sclerosing of the pericardium can be performed surgically
- Supplemental oxygen
- Volume expansion to maintain preload
- Inotropic drugs can be useful to increase CO without increasing SVR (see Table 93-2)
- Avoid positive pressure ventilation because of the associated decrease in venous return; keep patient breathing spontaneously
- Repeat the echocardiogram and CXR within 24 hours
Anesthesia for pericardial window
- Assess patient and stabilize hemodynamic status with goals of maintaining HR, preload, and afterload (i.e., fast, full, and tight) by giving crystalloids and using inotropes
- Consider placing arterial line and PAC
- Discuss type of procedure with surgeon and what depth of ...
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