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  • 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

Symptoms include

  • Dyspnea, tachypnea; patient typically sitting
  • Tachycardia
  • 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

  • PreOp
    • 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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