“Full of Burning Love”CIC March 11, 2014

Dr. Elliot Fagley, Dr. Lila Sueda, and Dr. Neel Patel,MD

CC: 48 y/o male with history of ischemic cardiomyopathy, presents with 7 day history of worsening dyspnea, orthopnea found to have a new large pericardial effusion requiring subxyphoid pericardial window.

ROS: No chest pain, fevers, chills or sweats

PMHx:CAD s/p stents x2 LADIschemic cardiomyopathy EF 11% VT s/p Bi-Vent ICDRecurrent A-fib s/p multiple cardioversions Protein S Deficiency History of CVA Seizure d/o

Medications: Amiodarone ASA Clonazepam Digoxin Furosemide Losartan Metolazone Phenytoin All: PNC and Macrolides

Metolazone Phenytoin Potassium chloride Pravastatin Ranitidine Spironolactone Warfarin

PE DOS:VS: BP 84/59 P: 74 O2 sat 95% on RA

Gen: NADNeck: elevated JVD, 10cmAirway: MPII, TM adequateCV: rrr no rubs or murmursResp: CTABPeripheral: +1 edema, warm, pink

Labs:CBC wnl, chem wnl INR 1.7, ESR incr.75

Etiology of pericardial effusion / pericarditisInfectious

o Viralo Bacterialo Tuberculosis

Non Infectiouso Traumatico Post cardiac surgeryo Malignancyo Uremia

Autoimmuneo Rheumatic fevero SLEo Drug induced (procainamide)

Adapted from Braunwald80 and Oakley81

Acute vs Chronic Effusion

Key concept: Rate of accumulation vs time for pericardial stretch

Cardiac TamponadeDefinition

◦ Fluid accumulation compromises cardiac output

Signs and Sx◦Beck’s Triad◦ECG Changes◦Echocardiographic features◦Pulsus Paradoxus (sensitivity and specificity)

ECG

Echo

*Can J Anesth/J Can Anesth (2011) 58:952–966

But wait, there’s more

Patient Anesthetic History: No problems with previous GA –appendectomy, device placment

Family Anesthetic History: Sister with Malignant Hyperthermia

What are your concerns?Hemodynamic compromise

◦Preload, Contractility, Afterload◦i.e Fast, full, strong

Malignant Hyperthermia◦Triggers for MH

Unsafe: ◦Volatile inhalation agents, succinylcholine

Safe: ◦ IV anesthetics including opioids, NDMBs, LAs, N2O,

antiemetics, reversal agents

Anesthetic Plan Our Plan:

◦ GA with ETT (patient declined LA with MAC) Monitors/Equipment:

◦ A-line, ASA monitors, TEE◦ Flush machine, Inhalation agents removed, C02 absorber

replaced, Induction:

◦ Midazolam, Ketamine◦ C-MAC

Maintenance:◦ Spontaneously breathing on N2O, remifentanil gtt,

dexmetomidine gtt,and ketamine boluses◦ Vasopressors: ephedrine and epinephrine boluses

Signs of MHIncreased metabolic activity

◦CO2 (>100mmHg), temp >39 (delayed sign), acidosis, >RR, tachycardia/dysrhythmias, <O2

Muscle rigidity Increased electrolytes K, Ca, and Na Rhabodomyolysis myoglobinemia, renal failure

DIC

Management of MHDiscontinue all anesthetic agents and hyperventilate

with 100% O2

Dantrolene 2.5mg/kg IV 10mg/kg

Cool the body

Treat acidosis (bicarbonate)Monitor UOP/diureseTreat hyperkalemiaCoag studies

Videos on MH

http://www.mhaus.org/videos

Follow up 1300cc of bloody pericardial fluid removed Tissue: fibrosis & chronic inflammation, ANA & RF negative Postoperative:

Extubated upon arrival to ICU. He remained hemodynamically stable until discharge.

5 months later:• Presented with severe hypokalemia and recurrent v-fib with

multiple AICD shocks• Also in persistent a-fib • Hospitalized for one week, treated for CHF• Underwent cardioversion to NSR• Several hours after cardioversion, PEA arrest, unable to

resuscitate

ReferencesCan J Anaesth 2011;58(10):952-66

Current Anaesthesia & Critical Care (2008) 19, 22–33

Miller’s Anesthesia 7th ed, 1948-49, 1188-89