**4.3 Variation in anesthesia methods**

Another variation of technique involves the consideration between general anesthesia and local anesthesia. General anesthesia remains the most common way of anesthesia for patients; it involves intubation and protection of airway under muscle paralysis, sedation and amnesia. But for patients who have hemodynamic compromise from pending cardiac tamponade due to a significant acute pericardial effusion, general anesthesia remains very high risk. In fact this group of patients is frequently the American Society of Anesthesiologists (ASA) class V, the highest-risk class. Many a surgeon have been demoralized after losing patients on the operating table, after this group of patients collapse upon giving the slightly amount of medication that could lower the vascular tone and reduce the blood pressures. Local anesthesia has been advocated to be safer in these patients, but often not practical as few patients could tolerate the pain of an anterior thoracotomy incision even with the best local infiltration. Mentioned later below, a subxiphoid incision could be more tolerable with this, and some surgeons have been successful with it. A new method in the middle ground could be non-intubated general anesthesia. This has been successful in reported VATS surgery [12]. Without muscle paralysis and using a laryngeal mask airway to continue spontaneous-assisted ventilation, this resulting loss of vascular tone could be reduced and perhaps reduce the risk of anesthesia. But the surgeon must also realize and cope with the increased muscle tone and continued ventilation of the lungs. Exposure needs to be ensured as the lung cannot be isolated in this setting.
