pericardial disease/tamponade 3/20

Question 1

how much fluid does pericardial space hold

Answer 1

Pericardial Space between the two layers/normally contains 15-20 ml serous fluid

Question 2

Signs/Symptoms Cardiac Tamponade

Answer 2

a- Cardiac distress, dyspnea
b- Beck’s Triad (hypotension, jugular venous distension, distant muffled heart sounds)
c- Pulsus paradoxus (exaggeration of the usual decrease in systolic BP >10 mmHg on inspiratio
d-tachycardia
e-low cardiac output
f-increased CVP
g-equalization of CVP and PAD

Question 3

pericardial effusion

Answer 3

“an inflammatory reaction (characteristic of acute pericarditis) which may be associated with accumulation of fluid in the pericardial space

Question 4

1. Causes of Tamponade (a,b,c)?

2. name one time a tamponade may be life saving?

Answer 4

1a. Blunt or sharp trauma to the chest and dissecting AAA’s
1b. Post cardiac surgical complications
1c. Expansions of pericardial effusions after pericarditis
2. Tamponade may be life-saving by preventing exsanguination from wounds to the heart or great vessels

Question 5

1. Accumulation of pericardial fluid causes an increase in…
2. Leading to what change in diastolic filling?
3. this does what to stroke volume and what kicks in to maintain___what?
4. what happens to cardiac output?
5. what happens to blood pressure?
6. what is the end result?

Answer 5

1. intrapericardial pressure….
2. Impaired diastolic filling
3. Decreased stroke volume (Decreased stroke
   volume results in activation of the sympathetic nervous system (tachycardia, vasoconstriction) in attempts to maintain cardiac output)
4. Decreased cardiac output
5. Hypotension
6. Failure of this compensatory mechanism results in cardiovascular collapse

Question 6

what does a tamponade look like?

2. what are the causitive factors (and the side effects)

Answer 6

1. like CHF
2. Reduced ventricular compliance → pulmonary and peripheral congestion fatigue →
   Dyspnea
   Fatigue
   Kussmaul’s sign –exaggerated jugular venous pulsation
   level with inspiration
   Hepatomegally, ascites
   Tachycardia

Question 7

1. what is a tamponade?
2. what does it limit?
3. what determines acuity of condition?
4. what parameter suffers most from tamponade (what happens)?

Answer 7

1□ Sudden increase of fluid into the pericardium with external pressure on the heart
2□ Increased pressure prevents complete filling of the heart before the next heart beat; Limits ventricular filling
3□ The rate of fluid accumulation determines the
development of acute life threatening conditions.
4□ ↓cardiac output

Question 8

Signs/Symptoms Cardiac Tamponade:

1. what are cardiac and respiratory symptoms?
2. what is the “signature” set of symptoms found with tamponade?
3. what can you see on the art line? how is it defined (how much of a change with what?
4. what signs would you see on a swan (equalization of what)?
5. CVP changes?
6. voltage/ rhythm changes?

Answer 8

1. Cardiac distress, dyspnea
2. Beck’s Triad (hypotension, jugular venous distension, distant muffled heart sounds)
3. Pulsus paradoxus (exaggeration of the usual decrease in systolic BP >10 mmHg on inspiration)
4. equalization of RAP and PAD (end diastolic) pressures
5. increased CVP
6. decreased voltage on rhythm, voltage alternans

Question 9

treatment of pericarditis:

1. acute:
   a. without effusion
   b. with effusion
2. chronic:
   a. what procedure is sometimes done for chronic?
   b. what may happen to the heart over time from chronic effusions?

Answer 9

1. acute pericarditis:
   a. if no effusion or scarring- tx underlying illness, treat with antibiotics
   b. if effusion present (or tamponade)-drain fluid; pericardiocentesis (?at bedside) or pericardial window (in OR).
2. chronic:
   a. pericardectomy (pericardial sac is removed)
   b. heart may have atrophy from prolonged constriction

Question 10

1. what is the defenitive treatment for tamponade?
2. what are the three methods of pericardial window?
3. how dramatic a change is a small amount of pericardial fluid?

Answer 10

1. treatment is relief of cardiac compression
2. a.subbxiphoid pericardiostomy; b.thoscopic pericardiostomy; c.thoracotomy with pericardiostomy
3. With gradual development, the pericardium can stretch to accommodate a large volume of fluid without a significant increase in pressure In a normal pericardial space, intrapericardial pressure rises with just 40-50 ml of fluid. (This is why tamponade can occur quickly). Rapid accumulation causes acute cardiac tamponade. Clinical effects depend on whether or not accumulated fluid is under increased pressure. However. there is a dramatic decrease in intrapericardial pressure from removing even a small amount of fluid.

Question 11

1. what is the montra for tamponade patients?

2. why?

Answer 11

1. “full, fast and tight”
□ Adequate volume
□ Maintain tachycardia 
□ Prevent hypotension 
2. since they have decreased stroke volume from compression, they need a faster (fast) rate to circulate the blood and need to be volumized (full) to maximize stroke volume; they to maintain blood pressure(tight)

Question 12

1. why must you choose anesthesia wisely with tamponade patient?
2. what should be determinde before anesthesia is administered?
3. what should your technique maintain for these patients?

Answer 12

1. Direct myocardial depression from induction agents can lead to severe myocardial depression and arrest!!!
2. Determine if the pt has a slow accumulating effusion or a rapidly developed tamponade
3. Choose a technique that maintains HR, volume, and contractility

Question 13

what is a good anesthetic regimen for a pericardial window surgery?

Answer 13

Induction agent: Ketamine (0.5-1.0 mg/kg) and succinylcholine or a benzodiazepines plus N2O (Stoelting)

Question 14

I. what should you ensure in regards to lines?

II. what other lines or equipment?

Answer 14

I. 	1.art line
	2. 2 large bore GOOD IVs (arms will be tucked)
	3. cvp
II.	1.Cardiopulmonary bypass machine
	2. TEE
	3. swan

Question 15

if tamponade is a trauma, what is the sequence of care?

Answer 15

1. trauma principles

2. RSI intubation (full stomach)

Question 16

1. what is recommended regarding ventilation of a pericardial window patient?
2. what should you avoid?
3. why?

Answer 16

1. Spontaneous ventilation is preferred but not feasibl (It is recommended that a patient undergoing surgery for cardiac tamponade be allowed to breath spontaneously until the chest is opened and the pericardium incised)
2. avoid vigorous positive pressure ventilation (high peep) until the pericardial space is drained
3. decreases venous return which inhibits the “full” of full, fast, tight

Question 17

1. what may be needed to over come decreased venous return (d//t compression)?
2. what can be used to increase this RA pressure?
3. what may be causing hypotension that can be corrected (hint: d/t hypoperfusion)

Answer 17

1. Increasing right atrial pressure to 25-30
   mmHg may be needed to overcome the effect of increased intrapericardial pressure on venous return
2. Use of inotropes to increase myocardial contractility and HR
   Example, isoproterenol, dopamine, dobutamine
   Atropine may me needed to treat bradycardia
   resulting from vagal reflexes
3. Correction of metabolic acidosis [result of low CO]

Question 18

pericardectomy:

1. performed for what?
2. how is it performed?
3. you may have to treat patient like an open heart because…?
4. how long before RAP returns to normal after pericardectomy?

Answer 18

1. Performed for tx of chronic constrictive pericarditis
2. Surgical stripping and removal of the adherent constricting pericardium
3. May be done while on CPB, especially to help prevent and control hemorrhage
4. Takes 3-4 months after surgery for RAP to return to normal

Question 19

what are complications of surgical manipulation and dissection of the adherent pericardium (pericardectomy) can lead to?

Answer 19

□ Bleeding (Potential for massive hemorrhage & associated symptoms: ascites, renal dysfunction)
□ Hypotension
□ Arrhythmias
□ Acute hemodynamic decompensation of this disease process is rare

Question 20

1. what should you differentiate prior to surgery regarding why you are doing the pericardectomy?
2. ONCE AGAIN… your technique should maintain patient’s what…?

Answer 20

□Determine if the pt has a slow accumulating effusion or a rapidly developed tamponade
□ Choose a technique that maintains HR, volume, and contractility