Pericardial Disease

Question 1

If a chronic pericardial effusion develops, the pericardium can hold up to ____ of fluid

Answer 1

1L

Question 2

Normally, the pericardial cavity holds __-__mL of fluid

Answer 2

20-50mL

The heart can’t handle acute accumulations of any more than this

Question 3

What is the typical pressure within the pericardium

Answer 3

Similar to pleural pressure, and varies with respiration between -4 and +4mmHg

Question 4

Function of the pericardium

Answer 4

Lubricates the heart
Facilitates motion within the sac
Protects the heart from excessive displacement
Maintains optimum shape of the heart
Applies compensatory hydrostatic pressure to the heart to compensate for alterations in gravitational force

Question 5

Is acute pericarditis an emergency?

Answer 5

YES!!!

Question 6

Causes of acute pericarditis and how is it diagnosed?

Answer 6

Causes:

• Viral infection
• MI (Dressler’s Syndrome)
  
  • -> autoimmune inflammatory reaction to myocardial neo-antigens formed as a result of an MI

Diagnosis:

• Sudden onset of severe chest pain that’s exaggerated by INSPIRATION
• DIFFUSE ST elevation across all leads, PR segment depression, T wave inversion
• Pericardial friction rub on auscultation

Question 7

Medical treatment for acute pericarditis

Answer 7

Pain and inflammation reduction

1) ASA or NSAIDs to reduce inflammation
2) Analgesics (very painful)
3) Corticosteroids

Question 8

Does pericarditis WITHOUT effusion alter cardiac function?

Answer 8

No.
It’s the effusion that’s the true problem.
Effusion = emergency surgery
No effusion = treat medically

Question 9

Acute Pericardial Effusion

Answer 9

Rapid effusion = no time for the heart to accommodate.

Even small volumes of 100-200cc will cause tamponade when accumulated rapidly.

Question 10

Gradual Pericardial Effusion

Answer 10

If gradual, the pericardium will stretch to accommodate the fluid.
Up to 1L of fluid can accumulate without significant increases in pressure on the heart.

Question 11

Diagnosis of pericardial effusion

Answer 11

ECHO

Question 12

What happens in cardiac tamponade?

Answer 12

The increase in pericardial pressure impairs diastolic filling. This shit is an emergency.

Question 13

S/S of cardiac tamponade

Answer 13

Hypotension (low CO and SV)
Increased CVP and JVD (stuff is backing up)
Muffled heart sounds
Low voltage on ECG (no filling = lack of starling force)
Pulsus paradoxus
Equalization of cardiac filling pressures
Tachypnea
SNS activation***

Question 14

Treatment for pericardial tamponade

Answer 14

Remove the fluid!

1) Pericardiocentesis
2) Subxiphoid pericardiostomy
3) Thoracic pericardiostomy (open or thoroscopic)

Question 15

Anesthetic management for cardiac tamponade

Answer 15

1) Maintain the SNS!!
2) Expand volume (try to increase filling pressures against the pericardium)
3) Increase contractility (isoproterenol)
4) Correct metabolic acidosis (reduce likelihood of dysrhythmia. May be in acidosis b/c probably in cardiogenic shock)

Question 16

Causes of restrictive pericarditis

Answer 16

Idiopathic
Previous cardiac surgery
Radiotherapy exposure
TB

Question 17

S/S of Constrictive Pericarditis

Answer 17

Low CO
High CVP, RAP, PCWP (because the heart can't relax)
JVD
Pulsus paradoxus
Fatigue
Atrial dysrhythmias
Edema
Ascites / hepatomegaly

Question 18

Treatment for restrictive pericarditis

Answer 18

Pericardiectomy

- Surgical stripping of adhesions constricting the pericardium

Question 19

Anesthetic management for constrictive pericarditis

Answer 19

Similar to effusion

1) Maintain SNS
2) Avoid bradycardia
3) Maintain intravascular volume
4) Use ketamine, etomidate, and pancuronium to minimize changes in HR, SVR, preload, and contractility
5) High blood loss with pericardiectomy –> be prepared for infusion