Anesthesia with Cardiac

Tamponade

By R3黃信豪
Brief history (1)
 A 1 y/o female patient, about 10.9 kg.
 Congenital VSD was diagnosed at birth.
 VSD repair was performed in 93-07-26
in NTUH.
 No residual VSD was noted in f/u TTE
report.
Brief history (2)
 Poor appetite and daily activity decreased
were noted for 3 days.
 Patient was sent to 金門縣立醫院, and
pericardial effusion was told. So patient was
transferred to our hospital in 93-08-11.
 Patient was admitted at 4C2 ICU, and TTE
was performed immediately. Pericardial
effusion was confirmed, so emergent
operation for effusion drainage was arranged.
Brief history (3)
 Patient was sent to OR with A-line inserted
and a 24G peripheral line.
 HR was about 135-150 per min. BP was
around 100/60 mmHg without any inotropic
agent, and would be dropped to 85/50 mmHg
when she calmed down. SpO2 was about 98-
100.
 No cyanosis or jugular vein engorged was
noted since patient came to the hospital.
Brief history (4)
 After CVS doctors arrived, induction was
performed.
medication: Ketamine 25 mg
Atropine 0.1mg
Nimbex 3 mg
intubation: with 5.0 ET tube fixed 13 cm
checked by stethoscope
 After intubation, ventilator was used.
Brief history (5)
 The HR was kept around 120-140 per min.
The BP was around 90/60 mmHg. SpO2 was
still about 100.
 pericardiotomy via subxiphoid approached for
effusion drainage was performed immediately.
About 50 ml clear and yellowish fluid was
drainage. Then BP was elevated to 120/ 70
mmHg after the procedure.
 After replacing a chest tube in pericardial
space for drainage, the wound was closed.
Then patient was sent to 4A2 ICU for further
care.
Discussion
Definition
 Cardiac tamponade: the accumulation of fluid in
the pericardium in an amount sufficient to cause
serious obstruction to the inflow of blood to
ventricle results in cardiac tamponade.
 The three principal features of tamponade
are:
1.elevation of intracardiac pressures
2.limitation of ventricular fillng
3.reduction of cardiac output
The pericardium, which
is the membrane
surrounding the
heart, is composed
of 2 layers. The
parietal pericardium
is the outer fibrous
layer; the visceral
pericardium is the
inner serous layer.
The pericardial space
normally contains
20-50 mL of fluid
 The most common causes are:
a. neoplastic disease
b. idiopathic pericarditis
c. uremia
d. the following cardiac operation
e. trauma:
 The amount of fluid necessary
to produce the critical state:
Acute tamponade: 150-200 ml
Chronic tamponade: 1000-2000 ml
The three phase of hemodynamic changes in cardiac
tamponade: ( by Reddy et. al.)

 Phase I: The accumulation of pericardial fluid causes

increased stiffness of the ventricle, requiring a higher
filling pressure. During this phase, the left and right
ventricular filling pressures are higher than the
intrapericardial pressure.
 Phase II: With further fluid accumulation, the
pericardial pressure increases above the ventricular
filling pressure, resulting in reduced cardiac output.
 Phase III: A further decrease in cardiac output occurs,
which is due to equilibration of pericardial and left
ventricular (LV) filling pressures.
The features of the cardiac
tamponade (1)

A.clinical features
1. Shortness of breath
2. Weakness and fatigue
3. Anxiety
4. tachycardia
5. Jugular vein engorged—Beck triad
6. Cyanosis
The features of the cardiac
tamponade (2)
 Beck triad:
1. increased jugular venous pressure
2. hypotension,
3. diminished heart sounds
 Pulsus paradoxus:
A greater than normal (10 mmHg) inspiratiory
decline in systolic arterial pressure.
 Kussmaul’s sign :paradoxical increasing
venous pressure during inspiratory
 Ewart’s sign :area of dullness, with bronchial
breath sounds and bronchophony below the angle
of the left scapula
 The features of the cardiac
tamponade (3)

 The ECG of cardiac tamponade:

1.Low electrical voltage
2.P-R segment depression
 ECG signs that are suggestive, but not diagnostic, of
pericardial effusion and cardiac tamponade. Because
these ECG findings cannot reliably identify these
conditions, we conclude that 12-lead ECG is poorly
diagnostic of pericardial effusion and cardiac tamponade
~~ by Mark J. Eisenberg, MD
The features of the cardiac
tamponade (4)
 The CXR of
cardiac
tamponade:
The x-ray may show
an enlarged cardiac
“silhouette” due to an
excessive volume of
pericardial fluid,
especially when more
than 200 milliliters of
fluid has built up in the
pericardium.
The features of the cardiac
tamponade (5)
 The
echocardiogram of
cardiac tamponade:
1. echo free space
between
epicardium and
pericardium
2. heart Swinging
The treatment of cardiac
tamponade (1)

 Medical care:
a.oxygen
b.volume expansion
c.bed rest with lower limbs elevation
d.inotropic agents use~dobutamine
The treatment of cardiac
tamponade (2)
 Invasive procedure:
a. Pericardiocentesis
b. Subxiphoid percutaneous drainage
c. Percutaneous balloon pericardiotomy
d. Surgical creation of a pericardial window
e. Pericardio-peritoneal shunt
f. Pericardiodesis or sclerosing the pericardium
g. Pericardiectomy
About the anesthesia plan in
cardiac tamponade.

 The plan should

1. include monitoring of the important
hemodynamic variables.
2. omit drugs and minimize manipulations that
decrease venous return, reduce heart rate,
produce hypotension, result in hypoxemia,
or impair ventricular contractility
The monitors needed for cardiac
tamponade

 SpO2
 A-line
 ECG –not for diagnosis, for arrhythmia
detection
 CVP
 Swan-Ganz catheterization
The route for induction
 Inhalation induction:
All modern volatile anesthetics, including
desflurane and sevoflurane, depress
contractile function in normal myocardium in
vitro and in vivo----Not suitable for the case
of cardiac tamponade!!!!
Intravenous induction:
etomidate or ketamine
 Ketamine etomidate Propofol midazolum
HR 0~+59 -5~+10 -10~+10 -14~+12
MAP 0~+40 0~-17 -10~-40 -12~-26
SVR 0~+33 -10~+14 -15~-25 0~-20
PAP +44~+47 -9~+8 0~-10 N
PVR 0~+33 -18~+6 0~-10 N
RAP +15~+33 N 0~-10 N
PAO N N N 0~-25
CI 0~+42 -20~+14 -10~-30 0~-25
LVSWI 0~+27 0~-33 -10~-20 -28~-42

Left Ventricular Stroke Work Index(LVSWI) =

SV/BSA * (MAP-PAWP) * 0.0136
 By “Hemodynamic response to ketamine and
diazepam in dogs with acute cardiac tamponade”
1. Ketamine, 2 mg/kg intravenously resulted in an
improvement of cardiac output from 1.2 +/- 0.5
L/min to 2.2 +/- 0.3 L/min (p less than 0.05 )
2. Five dogs with intrapericardial pressure above
10 mmHg did not respond to ketamine.
 Emergency subxiphoid percutaneous
drainage: This is a life-saving bedside
procedure.
The mode of ventilation
 Positive pressure ventilation
positive pressure ventilation will further
embarrasses venous return and cardiac
output – contraindication !!!
 Spontaneous ventilation
the best choice of cardiac tamponade
until the tamponade is relieved.
 The inotropes and
chronotropes
 Epinephrine - b21 2 mg/min
b1 + b2 2–10 mg/min
a1 ≥10 mg/minb
 Nor-epinephrine (Levophed) - a1 b1 >>b2
 Dopamine - Dopaminergic 0–3 mg/kg/min
b 3–10 mg/kg/min
a >10 mg/kg/minb
 Dobutamine - b1 >> b2 a
 Isoproterenol ( Isuprel ) - b1 > b2
Conclusion
 Removal of pericardial fluid is the definitive
and effective therapy for tamponade.
 Anesthesia plan is important for the patients
with cardiac tamponade.
 If general anesthesia is needed, adequate
monitors must be setup before induction.
 CVS doctors standby is important if emergent
drainage was necessary during induction.