Gastric POCUS, 3-Part Episode

The hemodynamic goals in cardiac tamponade include maintaining preload (“full”), maintaining slightly elevated heart rate (“fast”), and maintaining systemic vascular resistance (SVR) (“tight”). Premedication should be avoided if possible because it may compromise SVR or respiratory function. Given the dependence on SVR, the best options for induction include ketamine, etomidate, and opioids. Alternatively, inhaled induction with volatile anesthetics may be considered. In extreme cases, drainage using only local anesthetics may be necessary. An anesthetic technique that maintains spontaneous ventilation and avoids positive pressure ventilation prior to drainage of pericardial fluid is beneficial as positive pressure ventilation further impairs venous return and can precipitate hemodynamic collapse. A trial of positive pressure ventilation with low pressures can be used to determine the effect on blood pressure prior to drainage of fluid. Standard ASA monitors as well as an arterial catheter to monitor blood pressure throughout induction should be placed prior to induction along with large bore peripheral access. Induction of anesthesia should absolutely not be performed without the surgical team prepared, because there may be a need for emergent drainage of the effusion if hemodynamic collapse occurs with induction. Many centers advocate prepping and draping the patient as well prior to induction of anesthesia.