Patients presenting for pericardial drainage procedures require a thorough, but often urgent, preoperative evaluation in order to understand the etiology of the effusion and any associated hemodynamic instability, such as tamponade.
Echocardiography plays a central role in the diagnosis of effusion and pericardial tamponade and can guide drainage.
Thoracoscopic procedures and subxiphoid approaches are the most common techniques for definitive drainage of pericardial effusion. However, ultrasound-guided needle pericardiocentesis can be used for emergent drainage in the unstable patient.
The anesthetic technique needs to be tailored to the individual patient characteristics, but can be accomplished successfully with inhalational, as well as intravenous induction techniques. The hemodynamic goals of augmented preload with maintenance of afterload, contractility, and heart rate should be targets.
The patient is a 37-year-old woman with stage 4 breast cancer who presents with increasing shortness of breath, reduced exercise tolerance and intermittent chest discomfort. She has also complained of worsening headaches for the past few weeks. She has a history of receiving Adriamycin chemotherapy, interrupted for reasons unclear to her, and was healthy before her cancer diagnosis 3 years ago. She has been unable to lie flat for 24 hours and has poor venous access. She has steroid induced diabetes. Medications include lansoprazole, iron and lorazepam at night.
Vital signs: BP 90/40, HR 110, room air SaO289%.
Laboratory examination is notable for: hemoglobin 8.2, WBC 5.8, platelets 164, BUN 40, creatinine 1.4, glucose 145.
Chest wall echocardiogram revealed a large pericardial effusion.
She is listed for a pericardial window procedure via thoracoscopy.
Pericardial window procedures allow the drainage of fluid from the pericardial space and are performed with relative frequency by the cardiothoracic surgical team. In order to provide optimal anesthetic management for such patients, a thorough understanding of the associated pathophysiology and the various etiologies of pericardial effusion is essential.
Pericardial tamponade can occur in numerous acute conditions such as penetrating chest trauma, or present in the decompensated state of various subacute processes such as malignant tumors (Table 16–1). Although pericardial effusions can occur in isolation, they often occur in combination with other clinical conditions such as pleural effusions. This can confuse the clinical picture considerably, as symptoms of dyspnea and orthopnea can be secondary to the pleural effusion and/or other pulmonary involvement. Frequently the therapeutic intervention for pericardial effusion involves concomitant pleural drainage.
Table 16–1. Etiology of Pericardial Effusion/Pericarditis |Favorite Table|Download (.pdf)
Table 16–1. Etiology of Pericardial Effusion/Pericarditis
- Aortic aneurysm (leaking into pericardial sac)
- Post-cardiac surgery
- Acute myocardial infarction
- Post-myocardial infarction (Dressler syndrome)
- Renal insufficiency/uremia
- Post irradiation
- Rheumatic fever
- Rheumatoid arthritis
- Systemic lupus erythematosus
- Drug induced (procainamide)