Cardiac tamponade: Anesth management

Cardiac tamponade may occur if blood or other fluid collects within the pericardium, compressing the heart. Drainage via percutaneous pericardiocentesis may be indicated, especially if the patient is unstable prior to definitive treatment. In patients presenting for surgical treatment (most frequently subxiphoid pericardial window), the anesthetic goals are as follows: “Full (maintain preload), Fast (maintain HR), Tight (maintain SVR and BP)”

In general terms, most patients presenting for a subxiphoid pericardial window should undergo the procedure under local anesthesia with spontaneous ventilation and as little sedation as possible. If local anesthesia cannot be performed (or if tamponde occurs during a general anesthetic), the following principles should guide management.

Induction

• Induction of GA, particularly with positive pressure ventilation, can result in severe hypotension and cardiac arrest and spontaneous ventilation is preferred

• Have epinephrine available, consider starting a vasoactive infusion prior to induction (Tight)

• Ketamine may be the agent of choice (increases HR, contractility, and SVR while maintaining spontaneous ventilation)

• Consider inhalational induction to maintain spontaneous ventilation

• Etomidate is also an option as it has minimal cardiac depression

Access

• Large bore IV access

Monitoring

• Intra-arterial BP monitoring, line placement should not delay pericardial drainage in hemodynamically unstable patient

• TEE is optimal for intraoperative monitoring and confirmation of appropriate drainage due to surgical approach

Airway

• Intubation with spontaneous ventilation and without muscle relaxation is preferred

• Avoid positive pressure ventilation as increases in mean airway pressure can decrease preload (venous return) resulting in decreased stroke volume and cardiac output (Full)

• If mechanical ventilation required, ventilation strategy should use low tidal volumes and minimize PEEP

Maintenance

• Anesthesia should maintain elevated sympathetic tone (Tight, Fast)

Avoid “deep” anesthesia as it can result in cardiac depression, bradycardia, hypotension (vasodilation)

• Ketamine is probably the agent of choice

• Intra-cardiac volumes should be optimized with IV fluid administration to maintain preload and stroke volume (Full)

• Consider small doses of epinephrine to maintain chronotropy (increased HR) and ionotropy (increased contractility)

Other elements to consider

• Hemodynamics and possible cardiovascular collapse after induction (loss of sympathetic tone) or mechanical ventilation (especially with positive pressure)

• End organ damage secondary to decreased perfusion

• Rebound hypertension after tamponade is evacuated, may need to rapidly “deepen” anesthetic and have vasodilators and beta-blockers ready

• With fixed stroke volume -> CO is dependent on HR

• Uncontrolled bleeding or recurrence of tamponade is possible

• Atrial Fibrillation can occur -> consider emergent cardioversion if hemodynamically unstable