**4. Anaesthetic management**

#### **4.1 Pericardial effusions and tamponade**

#### *4.1.1 Pre-operatively*

Accumulation of fluid in the pericardial space is the primary problem, and therefore definitive drainage and relief of the raised intra-pericardial pressure are required [9, 12, 21, 22, 32]. The type of drainage procedure will depend on the aetiology of the pericardial effusion and the clinical condition of the patient. A multidisciplinary team approach is needed, and a thorough pre-operative workup should be done if time allows. Clinical history and examination should be carried out focusing on pertinent physiological symptoms and signs to identify the cause and severity of the pathology.

Patients fall broadly into two categories: pericardial effusion with pretamponade physiology and a haemodynamically stable clinical picture or features of tamponade are present on TTE with haemodynamic consequences and instability. The presence of orthopnoea and pulsus paradoxus is a sign of a severely compromised patient.

If there is haemodynamic compromise, the safest and quickest drainage option needs to be selected. Haemodynamic goals pre-drainage should follow the "Airway, Breathing, Circulation" approach bearing in mind the pathophysiology of tamponade as discussed above. If required, a definitive airway management strategy should be employed and supplemental oxygen administered in order to optimise the delivery of oxygen to tissues during the decreased cardiac output state. Positive pressure ventilation should be avoided, but if required, peak airway pressures and PEEP should be minimised to avoid precipitation of cardiovascular collapse.

Large-bore peripheral access is needed for fluid and blood product administration and should be secured before any pharmacological agents are administered. Invasive arterial and central venous lines are needed for monitoring but should not delay drainage for patients in extremis.

Optimisation of preload is advised pre-operatively as hypovolaemia will worsen tamponade physiology. Dynamic measures of fluid responsiveness should be used to guide fluid therapy. A single, individualised fluid challenge may be beneficial, and outcome-based measures should be used to assess response. Improvement will be if the patient reports relief of symptoms or markers of end-organ perfusion improve.

Caution needs to be exercised as too much fluid will worsen the ventricular interdependence and further compromise cardiac output. Volume loading predrainage may also exacerbate volume overload post-drainage. Temporary haemodynamic support with a vasopressor agent may be more appropriate than excessive fluid administration to maintain blood pressure in the pre-operative period.

#### *4.1.2 Types of drainage procedures*

Needle pericardiocentesis consists of percutaneous placement of a catheter into the pericardial sac to facilitate external drainage of the effusion [24, 25]. Specific anatomical landmarks with echocardiographic and/or fluoroscopic guidance are used to insert the catheter using a Seldinger technique. This can be done in an awake patient with supplemental local anaesthetic and is the treatment of choice for an iatrogenic tamponade caused in the interventional suite [38]. The subcostal approach is safest for a blind procedure in the emergency setting where TTE may not be available. The apical and parasternal approaches may also be used. Pericardiocentesis is

**83**

treatment.

*Anaesthesia for Patients with Pericardial Disease DOI: http://dx.doi.org/10.5772/intechopen.82540*

method of drainage in hypotensive patients.

nearing cardiovascular collapse.

*4.1.3 Complications of drainage procedures*

tamponade.

complications.

pressure and heart rate.

leading to pulmonary oedema.

*4.1.4 Anaesthetic techniques*

diagnostic and therapeutic as drained fluid can be sent for testing. It is the preferred

Surgical procedures include a pericardial window performed via a substernal approach. Anterolateral thoracotomy and video-assisted thoracoscopic approaches may also be used. Surgical drainage allows for the formation of a pleuropericardial window which allows ongoing drainage of the effusion and decreases the risk of recurrent tamponade. Surgical drainage is preferred for haemopericardium, purulent effusions and recurrent disease. The sub-xiphoid approach consists of a small sub-xiphoid incision made to relieve pressure and directly visualise the parietal pericardium. The advantages of this approach include its effectiveness and simplicity and that it can be performed under local anaesthesia if needed for the patient

Needle pericardiocentesis under ultrasound guidance is considered a life-saving procedure with morbidity rates of 1–3% and a mortality rate of <1% [21, 41, 42, 50]. Puncture and/or rupture of myocardium or coronary vessels; arrhythmias; myocardial infarction; subsequent infection or damage to surrounding structures such as the stomach, liver or lung; and re-accumulation are some of the rare

In the case of a loculated effusion, the pericardiocentesis may not be effective in relieving the chamber compression, and more definitive surgery may be needed. Paradoxical haemodynamic deterioration following relief of pericardial tamponade is sometimes encountered because of vasovagal effects with decreases in blood

*Pericardial decompression syndrome* [21, 50] is defined as an unexpected decline in haemodynamic parameters associated with pulmonary oedema and global LV dysfunction. It usually occurs following surgical drainage of large, chronic effusions, but the incidence is rare <5%, and in most patients, there is no discernible reason for the ventricular dysfunction observed. The cause is unknown but may be related to increased interventricular interdependence. The sudden increase in preload and ventricular filling causes an abrupt increase in systolic wall stress, myocardial stunning and volume overload with acute left ventricular failure. Sudden increases in left ventricular end-diastolic pressures are transmitted to the pulmonary circulation with increases in pulmonary pressures and extravasation of fluid into the alveoli

All patients require adequate peripheral access and standard ASA monitoring prior to any anaesthetic agent being administered [12, 21, 22, 32, 49, 51–54]. It may also be necessary to institute invasive monitoring via arterial and central venous lines when appropriate, ensuring that insertion of the lines does not delay definitive

The anaesthetic technique chosen will depend on the clinical condition and haemodynamic stability of the patient, any concomitant co-morbidities, the aetiology of the effusion and the procedure being performed. There are some advantages to performing general anaesthesia over local anaesthesia and sedation. Patient comfort

Percutaneous balloon pericardiotomy is performed in a similar manner to TTE-guided pericardiocentesis and is effective in patients with malignant effusions. A balloon is used to generate a pericardial window to prevent recurrence of the

#### *Anaesthesia for Patients with Pericardial Disease DOI: http://dx.doi.org/10.5772/intechopen.82540*

*Inflammatory Heart Diseases*

*4.1.1 Pre-operatively*

mised patient.

improve.

**4. Anaesthetic management**

and severity of the pathology.

delay drainage for patients in extremis.

*4.1.2 Types of drainage procedures*

**4.1 Pericardial effusions and tamponade**

Accumulation of fluid in the pericardial space is the primary problem, and therefore definitive drainage and relief of the raised intra-pericardial pressure are required [9, 12, 21, 22, 32]. The type of drainage procedure will depend on the aetiology of the pericardial effusion and the clinical condition of the patient. A multidisciplinary team approach is needed, and a thorough pre-operative workup should be done if time allows. Clinical history and examination should be carried out focusing on pertinent physiological symptoms and signs to identify the cause

Patients fall broadly into two categories: pericardial effusion with pre-

tamponade physiology and a haemodynamically stable clinical picture or features of tamponade are present on TTE with haemodynamic consequences and instability. The presence of orthopnoea and pulsus paradoxus is a sign of a severely compro-

If there is haemodynamic compromise, the safest and quickest drainage option needs to be selected. Haemodynamic goals pre-drainage should follow the "Airway, Breathing, Circulation" approach bearing in mind the pathophysiology of tamponade as discussed above. If required, a definitive airway management strategy should be employed and supplemental oxygen administered in order to optimise the delivery of oxygen to tissues during the decreased cardiac output state. Positive pressure ventilation should be avoided, but if required, peak airway pressures and PEEP should be minimised to avoid precipitation of cardiovascular collapse.

Large-bore peripheral access is needed for fluid and blood product administration and should be secured before any pharmacological agents are administered. Invasive arterial and central venous lines are needed for monitoring but should not

Optimisation of preload is advised pre-operatively as hypovolaemia will worsen tamponade physiology. Dynamic measures of fluid responsiveness should be used to guide fluid therapy. A single, individualised fluid challenge may be beneficial, and outcome-based measures should be used to assess response. Improvement will be if the patient reports relief of symptoms or markers of end-organ perfusion

Caution needs to be exercised as too much fluid will worsen the ventricular interdependence and further compromise cardiac output. Volume loading predrainage may also exacerbate volume overload post-drainage. Temporary haemodynamic support with a vasopressor agent may be more appropriate than excessive fluid administration to maintain blood pressure in the pre-operative period.

Needle pericardiocentesis consists of percutaneous placement of a catheter into the pericardial sac to facilitate external drainage of the effusion [24, 25]. Specific anatomical landmarks with echocardiographic and/or fluoroscopic guidance are used to insert the catheter using a Seldinger technique. This can be done in an awake patient with supplemental local anaesthetic and is the treatment of choice for an iatrogenic tamponade caused in the interventional suite [38]. The subcostal approach is safest for a blind procedure in the emergency setting where TTE may not be available. The apical and parasternal approaches may also be used. Pericardiocentesis is

**82**

diagnostic and therapeutic as drained fluid can be sent for testing. It is the preferred method of drainage in hypotensive patients.

Percutaneous balloon pericardiotomy is performed in a similar manner to TTE-guided pericardiocentesis and is effective in patients with malignant effusions. A balloon is used to generate a pericardial window to prevent recurrence of the tamponade.

Surgical procedures include a pericardial window performed via a substernal approach. Anterolateral thoracotomy and video-assisted thoracoscopic approaches may also be used. Surgical drainage allows for the formation of a pleuropericardial window which allows ongoing drainage of the effusion and decreases the risk of recurrent tamponade. Surgical drainage is preferred for haemopericardium, purulent effusions and recurrent disease. The sub-xiphoid approach consists of a small sub-xiphoid incision made to relieve pressure and directly visualise the parietal pericardium. The advantages of this approach include its effectiveness and simplicity and that it can be performed under local anaesthesia if needed for the patient nearing cardiovascular collapse.

#### *4.1.3 Complications of drainage procedures*

Needle pericardiocentesis under ultrasound guidance is considered a life-saving procedure with morbidity rates of 1–3% and a mortality rate of <1% [21, 41, 42, 50].

Puncture and/or rupture of myocardium or coronary vessels; arrhythmias; myocardial infarction; subsequent infection or damage to surrounding structures such as the stomach, liver or lung; and re-accumulation are some of the rare complications.

In the case of a loculated effusion, the pericardiocentesis may not be effective in relieving the chamber compression, and more definitive surgery may be needed.

Paradoxical haemodynamic deterioration following relief of pericardial tamponade is sometimes encountered because of vasovagal effects with decreases in blood pressure and heart rate.

*Pericardial decompression syndrome* [21, 50] is defined as an unexpected decline in haemodynamic parameters associated with pulmonary oedema and global LV dysfunction. It usually occurs following surgical drainage of large, chronic effusions, but the incidence is rare <5%, and in most patients, there is no discernible reason for the ventricular dysfunction observed. The cause is unknown but may be related to increased interventricular interdependence. The sudden increase in preload and ventricular filling causes an abrupt increase in systolic wall stress, myocardial stunning and volume overload with acute left ventricular failure. Sudden increases in left ventricular end-diastolic pressures are transmitted to the pulmonary circulation with increases in pulmonary pressures and extravasation of fluid into the alveoli leading to pulmonary oedema.

#### *4.1.4 Anaesthetic techniques*

All patients require adequate peripheral access and standard ASA monitoring prior to any anaesthetic agent being administered [12, 21, 22, 32, 49, 51–54]. It may also be necessary to institute invasive monitoring via arterial and central venous lines when appropriate, ensuring that insertion of the lines does not delay definitive treatment.

The anaesthetic technique chosen will depend on the clinical condition and haemodynamic stability of the patient, any concomitant co-morbidities, the aetiology of the effusion and the procedure being performed. There are some advantages to performing general anaesthesia over local anaesthesia and sedation. Patient comfort

#### *Inflammatory Heart Diseases*

is improved, surgical and operating conditions are optimised and TOE may be employed to guide surgery and ensure adequate evacuation of the effusion [21].

Regardless of the technique chosen, the following haemodynamic goals should be adhered to increase cardiac output, maintain heart rate, maintain sinus rhythm, maintain systemic vascular resistance and left ventricular afterload as tamponade is a fixed output state and ensure an appropriate ventilatory strategy to decrease right atrial and pulmonary pressures. This will augment right atrial filling and decrease right ventricular afterload to promote forward flow through the lungs and maintain left-sided filling pressures from the pulmonary veins.

Local anaesthetic infiltration with supplemental sedation using ketamine, midazolam or fentanyl may be sufficient for pericardiocentesis and sub-xiphoid windows in the less stable patients who are co-operative. Midazolam is a potent, short-acting benzodiazepine that may be used to facilitate drainage procedures under local anaesthesia. Doses of 0.01–0.03 mg/kg may be given slowly and titrated to effect. Respiratory depressant effects are exaggerated with concomitant administration of opioids and other central nervous system depressant drugs.

If general anaesthetic is required, haemodynamic goals remain the same as above. Supplemental administration of fluid and/or blood products with vasopressor or inotropic infusions may be required to support cardiac output.

#### *4.1.4.1 Intraoperatively*

Induction of anaesthesia may be associated with severe hypotension and subsequent cardiovascular collapse. The suppression of sympathetic drive from induction agents such as propofol or thiopentone causes vasodilation and bradycardia. Coupled with the deleterious effects of mechanical ventilation as described above, induction of anaesthesia may cause cardiovascular collapse in patients at risk.

The avoidance of respiratory depressant drugs and positive pressure ventilation should be the technique of choice if possible. Spontaneous respiration with a volatile agent such as sevoflurane is ideal if tolerated by the patient. Conditions which may preclude inhalational induction include significant aspiration risk, morbid obesity, severe orthopnoea or an unco-operative patient [12].

Sevoflurane is a fluorinated methyl isopropyl ether anaesthetic agent that is nonpungent, causes minimal airway irritation and is well tolerated by awake, spontaneously breathing patients. It causes a dose-dependent decrease in mean arterial pressure by causing vasodilation and reducing systemic vascular resistance. At concentrations of more than 1.5 minimum alveolar concentration (MAC), increases in heart rate may occur. Nominal changes in cardiac output and stroke volume occur with careful titration. Infusions of vasopressor agents may be required to maintain blood pressures while acquiring adequate depth of anaesthesia with a volatile agent. Adequate depth of anaesthesia should be confirmed before any attempts at manipulation of the airway.

IV induction can be used for more stable patients with no evidence of tamponade. Surgical preparation and draping to facilitate emergency drainage is advisable if IV induction is to be used. IV induction agents need to be carefully selected. Ketamine and etomidate are recommended agents of choice as they will have the least vasodilatory effects.

Ketamine is a phencyclidine derivative that induces a dissociative anaesthetic state. The cardiovascular effects mimic those of sympathetic nervous system stimulation. Systemic blood pressure, heart rate and cardiac output are all increased after intravenous induction doses of 1–2 mg/kg which satisfy the haemodynamic goals required in patients with tamponade pathophysiology. Although there is a theoretical concern about increases in right ventricular afterload with ketamine, it

**85**

*Anaesthesia for Patients with Pericardial Disease DOI: http://dx.doi.org/10.5772/intechopen.82540*

cardiovascular reserve.

narcotics required.

further decreases in cardiac output.

*4.1.5 Airway management*

has been used safely in patients for both adjunctive sedation and general anaesthesia. Critically ill patients may respond with unexpected decreases in blood pressure and cardiac output, reflecting a depletion of catecholamine stores and the unmasking of ketamine's direct myocardial depressant effects. Caution must therefore be exercised with these patients. In this instance, it may be more appropriate to use

Etomidate is a unique carboxylated imidazole-containing compound that exerts

Propofol is a substituted isopropyl phenol which causes rapid onset of anaesthesia at induction doses of 1.5–2.5 mg/kg when administered intravenously. Its mechanism of action is to modulate GABA receptors causing hyperpolarisation and inhibition of the postsynaptic cell membrane. Propofol causes decreases in systemic vascular resistance, negative inotropy and bradycardia. Vasodilation is mediated by the activation of protein kinase C, increased concentrations of nitric oxide and calcium channelblocking effects at a cellular level. This effect is present on both sides of the vascular system with arterial- and veno-dilation causing decreases in preload and afterload. Propofol has a depressant effect on the heart rate by decreasing the baroreceptor response to a drop in blood pressure [51]. These effects are exaggerated in patients with tamponade, and the use of propofol at induction doses is not recommended. Potent opioid agonists, such as fentanyl, are recommended for use in varying doses for both sedation and anaesthesia in patients with cardiac tamponade coming for drainage procedures. They exhibit superior cardiac stability when compared with morphine and are useful adjuncts to provide analgesia and reduce the dose of

Inotropic and vasopressor support should be anticipated, immediately available and used as needed to maintain haemodynamic goals at induction of anaesthesia. The positive inotropic effects of catecholamine-enhancing drugs may be limited in patients with tamponade [32]. This may be because patients are already operating at maximum sympathetic stimulation as a compensatory mechanism for the low cardiac output state. The choice of inotropic agent will depend on the patient's clinical condition. Those agents with inodilator properties may improve coronary perfusion initially, but no increase in other organ perfusion has been shown. Caution should be exercised and drugs titrated in at low doses with continuous assessment of haemodynamic response. Vasopressor agents are useful to maintain afterload but should be avoided in patients with normal blood pressure as their use may cause

Securing a definitive airway early and in the safest way possible is recommended. Endotracheal intubation allows for adequate control of ventilation and oxygenation. Mechanical ventilation may increase right ventricular afterload and decrease forward flow through the right ventricular outflow tract. This will in turn increase right ventricular end-diastolic pressures, worsen interventricular septal shift, further compromise left ventricular filling and negatively impact cardiac output. With an appropriate ventilatory strategy, however, the effect of mechanical ventilation can be minimised. The lowest possible inspiratory pressures and PEEP to

maintain minute volume and oxygenation should be used [21].

local anaesthesia with supplemental sedation doses of ketamine instead.

its anaesthetic effect by binding to the GABAA receptor and enhancing GABA binding. Myocardial depressant effects are minimal and contractility is preserved. Nominal changes in heart rate, stroke volume and cardiac output are noted after induction doses of 0.3 mg/kg. This superior cardiovascular stability profile makes etomidate the recommended IV induction agent for patients with little or no

#### *Anaesthesia for Patients with Pericardial Disease DOI: http://dx.doi.org/10.5772/intechopen.82540*

*Inflammatory Heart Diseases*

*4.1.4.1 Intraoperatively*

lation of the airway.

least vasodilatory effects.

is improved, surgical and operating conditions are optimised and TOE may be employed to guide surgery and ensure adequate evacuation of the effusion [21]. Regardless of the technique chosen, the following haemodynamic goals should be adhered to increase cardiac output, maintain heart rate, maintain sinus rhythm, maintain systemic vascular resistance and left ventricular afterload as tamponade is a fixed output state and ensure an appropriate ventilatory strategy to decrease right atrial and pulmonary pressures. This will augment right atrial filling and decrease right ventricular afterload to promote forward flow through the lungs and maintain

Local anaesthetic infiltration with supplemental sedation using ketamine, midazolam or fentanyl may be sufficient for pericardiocentesis and sub-xiphoid windows in the less stable patients who are co-operative. Midazolam is a potent, short-acting benzodiazepine that may be used to facilitate drainage procedures under local anaesthesia. Doses of 0.01–0.03 mg/kg may be given slowly and titrated to effect. Respiratory depressant effects are exaggerated with concomitant adminis-

If general anaesthetic is required, haemodynamic goals remain the same as above. Supplemental administration of fluid and/or blood products with vasopres-

Induction of anaesthesia may be associated with severe hypotension and subsequent cardiovascular collapse. The suppression of sympathetic drive from induction agents such as propofol or thiopentone causes vasodilation and bradycardia. Coupled with the deleterious effects of mechanical ventilation as described above, induction of anaesthesia may cause cardiovascular collapse in patients at risk.

The avoidance of respiratory depressant drugs and positive pressure ventilation should be the technique of choice if possible. Spontaneous respiration with a volatile agent such as sevoflurane is ideal if tolerated by the patient. Conditions which may preclude inhalational induction include significant aspiration risk, morbid

Sevoflurane is a fluorinated methyl isopropyl ether anaesthetic agent that is nonpungent, causes minimal airway irritation and is well tolerated by awake, spontaneously breathing patients. It causes a dose-dependent decrease in mean arterial pressure by causing vasodilation and reducing systemic vascular resistance. At concentrations of more than 1.5 minimum alveolar concentration (MAC), increases in heart rate may occur. Nominal changes in cardiac output and stroke volume occur with careful titration. Infusions of vasopressor agents may be required to maintain blood pressures while acquiring adequate depth of anaesthesia with a volatile agent. Adequate depth of anaesthesia should be confirmed before any attempts at manipu-

IV induction can be used for more stable patients with no evidence of tamponade. Surgical preparation and draping to facilitate emergency drainage is advisable if IV induction is to be used. IV induction agents need to be carefully selected. Ketamine and etomidate are recommended agents of choice as they will have the

Ketamine is a phencyclidine derivative that induces a dissociative anaesthetic state. The cardiovascular effects mimic those of sympathetic nervous system stimulation. Systemic blood pressure, heart rate and cardiac output are all increased after intravenous induction doses of 1–2 mg/kg which satisfy the haemodynamic goals required in patients with tamponade pathophysiology. Although there is a theoretical concern about increases in right ventricular afterload with ketamine, it

tration of opioids and other central nervous system depressant drugs.

sor or inotropic infusions may be required to support cardiac output.

obesity, severe orthopnoea or an unco-operative patient [12].

left-sided filling pressures from the pulmonary veins.

**84**

has been used safely in patients for both adjunctive sedation and general anaesthesia. Critically ill patients may respond with unexpected decreases in blood pressure and cardiac output, reflecting a depletion of catecholamine stores and the unmasking of ketamine's direct myocardial depressant effects. Caution must therefore be exercised with these patients. In this instance, it may be more appropriate to use local anaesthesia with supplemental sedation doses of ketamine instead.

Etomidate is a unique carboxylated imidazole-containing compound that exerts its anaesthetic effect by binding to the GABAA receptor and enhancing GABA binding. Myocardial depressant effects are minimal and contractility is preserved. Nominal changes in heart rate, stroke volume and cardiac output are noted after induction doses of 0.3 mg/kg. This superior cardiovascular stability profile makes etomidate the recommended IV induction agent for patients with little or no cardiovascular reserve.

Propofol is a substituted isopropyl phenol which causes rapid onset of anaesthesia at induction doses of 1.5–2.5 mg/kg when administered intravenously. Its mechanism of action is to modulate GABA receptors causing hyperpolarisation and inhibition of the postsynaptic cell membrane. Propofol causes decreases in systemic vascular resistance, negative inotropy and bradycardia. Vasodilation is mediated by the activation of protein kinase C, increased concentrations of nitric oxide and calcium channelblocking effects at a cellular level. This effect is present on both sides of the vascular system with arterial- and veno-dilation causing decreases in preload and afterload. Propofol has a depressant effect on the heart rate by decreasing the baroreceptor response to a drop in blood pressure [51]. These effects are exaggerated in patients with tamponade, and the use of propofol at induction doses is not recommended.

Potent opioid agonists, such as fentanyl, are recommended for use in varying doses for both sedation and anaesthesia in patients with cardiac tamponade coming for drainage procedures. They exhibit superior cardiac stability when compared with morphine and are useful adjuncts to provide analgesia and reduce the dose of narcotics required.

Inotropic and vasopressor support should be anticipated, immediately available and used as needed to maintain haemodynamic goals at induction of anaesthesia. The positive inotropic effects of catecholamine-enhancing drugs may be limited in patients with tamponade [32]. This may be because patients are already operating at maximum sympathetic stimulation as a compensatory mechanism for the low cardiac output state. The choice of inotropic agent will depend on the patient's clinical condition. Those agents with inodilator properties may improve coronary perfusion initially, but no increase in other organ perfusion has been shown. Caution should be exercised and drugs titrated in at low doses with continuous assessment of haemodynamic response. Vasopressor agents are useful to maintain afterload but should be avoided in patients with normal blood pressure as their use may cause further decreases in cardiac output.

#### *4.1.5 Airway management*

Securing a definitive airway early and in the safest way possible is recommended. Endotracheal intubation allows for adequate control of ventilation and oxygenation. Mechanical ventilation may increase right ventricular afterload and decrease forward flow through the right ventricular outflow tract. This will in turn increase right ventricular end-diastolic pressures, worsen interventricular septal shift, further compromise left ventricular filling and negatively impact cardiac output. With an appropriate ventilatory strategy, however, the effect of mechanical ventilation can be minimised. The lowest possible inspiratory pressures and PEEP to maintain minute volume and oxygenation should be used [21].

#### *Inflammatory Heart Diseases*

The choice of endotracheal tube will depend on the procedure. For example, one-lung ventilation may be needed to facilitate surgery in thoracotomy and videoassisted thoracoscopic surgery (VATS). The time taken to insert a double-lumen tube and check its position may be detrimental in an unstable patient. Under these circumstances, placing a single-lumen tube with a bronchial blocker may be more appropriate.

If the patient is very unstable, the safest option may be to perform a sub-xiphoid window initially under local anaesthetic to relieve the tamponade. General anaesthesia may then be more safely induced.

#### *4.1.6 Maintenance of anaesthesia*

General anaesthesia care including intraoperative acid–base management, correction of electrolyte abnormalities, temperature and glucose control is required as for all high-risk patients coming for a procedure. These patients may present in a decompensated state which negates pre-operative optimisation of their condition. In the case of any emergency surgery, ongoing resuscitation is required even after the patient has been safely anaesthetised.

IV opioids, propofol, ketamine and volatile agents can all be used if they are tolerated and the haemodynamics remain stable. Careful titration of agents rather than specified doses should be employed. Muscle relaxants should only be used once the patient can tolerate positive pressure ventilation. The choice of neuromuscular-blocking agent will depend on the onset and duration of action required. The newer agents from both the aminosteroid and benzylisoquinoline groups of intermediate-acting neuromuscular-blocking agents are appropriate as they do not exhibit significant cardiovascular effects.

Continuous infusions of inotropes and pressors may be needed and must be continued on a case-by-case basis.

Because of surgical handling of the heart, intraoperative arrhythmias are common and should be anticipated. A defibrillator and antiarrhythmic drugs should be immediately available and standard Advanced Cardiac Life Support (ACLS) algorithms employed to manage peri-operative arrhythmias.

Transfusion triggers and the need for intraoperative administration of blood and clotting factors should be discussed and decided by the multidisciplinary team before induction. Ongoing fluid and blood product resuscitation may be required. Adequate haemoglobin levels to ensure optimal oxygen-carrying capacity is needed and should be individualised per case. Peri-operative monitoring of the patient's coagulation status with thromboelastography (TEG) is advised in order to guide targeted administration of plasma products and pharmacological agents that may be required.

Because intrinsic myocardial function is generally preserved in pericardial effusion and tamponade, once the tamponade is relieved, there is usually a dramatic improvement in haemodynamics. At this point, vasopressor and inotropic infusions should be reviewed and weaned if appropriate. The use of vasodilator therapy is controversial and only indicated if there is associated systemic hypertension and elevated systemic vascular resistance [32].

#### *4.1.6.1 Post-operatively*

Patients should be transferred to a high-dependency unit for continuation of care. Ongoing monitoring is necessary to assess for recurrence of tamponade, ongoing bleeding and continuation of cardiovascular and ventilatory support.

**87**

resection [49, 58].

*Anaesthesia for Patients with Pericardial Disease DOI: http://dx.doi.org/10.5772/intechopen.82540*

*4.2.1 Types of pericardiectomy*

**4.2 Pericardiectomy for constrictive pericarditis**

provide definitive resection and optimise benefit [49, 55].

ventricles because of severe myo-pericardial adhesions.

visceral pericardium may be required [49].

*4.2.2 Complications associated with pericardiectomy*

Pericardiectomy is the only definitive treatment for established constriction, and

Pericardial stripping is carried out via sternotomy or lateral thoracotomy with or without cardiopulmonary bypass support [49]. Total resection is extremely difficult to perform via a thoracotomy, and median sternotomy is the preferred approach to

*Total pericardiectomy* is when wide excision of the pericardium is performed. The anatomical borders consist of the phrenic nerves posteriorly, the great vessels and intra-pericardial portion of the superior vena cava/right atrial junction superiorly

*Radical resection* is the removal of the pericardium including the anterolateral and diaphragmatic surfaces of the left and right ventricles with careful dissection posterior to the phrenic nerves to leave the left and right phrenic pedicles intact. Epicardial involvement may be missed at surgery leading to persistent constrictive physiology post-operatively. Reoperation to remove the diseased epicardium or

The need for cardiopulmonary bypass (CPB) should be individualised per case. Studies suggest that mortality rates are higher in patients who required CPB, but data may be skewed because its use is usually reserved for patients with a poor pre-operative status. Other indications include any coexisting cardiac conditions that may require intervention, previous cardiac surgery or partial pericardiectomy, a heavily calcified pericardial "cocoon" encasing all four cardiac chambers, post mediastinal irradiation and unintentional surgical damage to cardiac structures intraoperatively [49].

Persistent constrictive physiology and abnormal diastolic filling patterns may be seen in a percentage of patients even after successful surgery. In conjunction with symptomatic improvement, normalisation of pressure-volume loops and echocardiographic findings post pericardiectomy are used as markers of successful

Pericardiectomy is a very technically challenging operation with significant morbidity and mortality performed in high-risk patients [49, 54–57, 59]. Intraoperative complications may contribute significantly to poor outcomes. Sufficient preoperative preparation prior to induction of anaesthesia is paramount to ensuring

Massive haemorrhage should be anticipated with contingency plans in place before the administration of any anaesthetic agents. Timeous activation of a massive transfusion protocol is necessary. Cardiopulmonary bypass support should be immediately available with cannulation of femoral vessels under local anaesthesia

patient safety, and a multidisciplinary team approach should be used.

*Partial pericardiectomy* is defined as incomplete decortication of one or both

and the diaphragm and inferior vena cava/right atrial junction inferiorly.

most studies suggest that resection should be as complete as technically feasible [49, 54–57]. A retrospective review by Nozohoor et al. showed that radical pericardiectomy was associated with improved functional status and 10-year survival rates of 94% compared to 55% with subtotal pericardiectomy [55]. Bozbuga et al. also showed that performing early radical resection in combination with appropriate chemotherapeutic agents translated into the best outcomes in patients with tuberculous disease [56].

*Inflammatory Heart Diseases*

thesia may then be more safely induced.

the patient has been safely anaesthetised.

exhibit significant cardiovascular effects.

elevated systemic vascular resistance [32].

*4.1.6.1 Post-operatively*

algorithms employed to manage peri-operative arrhythmias.

continued on a case-by-case basis.

*4.1.6 Maintenance of anaesthesia*

appropriate.

The choice of endotracheal tube will depend on the procedure. For example, one-lung ventilation may be needed to facilitate surgery in thoracotomy and videoassisted thoracoscopic surgery (VATS). The time taken to insert a double-lumen tube and check its position may be detrimental in an unstable patient. Under these circumstances, placing a single-lumen tube with a bronchial blocker may be more

If the patient is very unstable, the safest option may be to perform a sub-xiphoid window initially under local anaesthetic to relieve the tamponade. General anaes-

General anaesthesia care including intraoperative acid–base management, correction of electrolyte abnormalities, temperature and glucose control is required as for all high-risk patients coming for a procedure. These patients may present in a decompensated state which negates pre-operative optimisation of their condition. In the case of any emergency surgery, ongoing resuscitation is required even after

IV opioids, propofol, ketamine and volatile agents can all be used if they are tolerated and the haemodynamics remain stable. Careful titration of agents rather than specified doses should be employed. Muscle relaxants should only be used once the patient can tolerate positive pressure ventilation. The choice of neuromuscular-blocking agent will depend on the onset and duration of action required. The newer agents from both the aminosteroid and benzylisoquinoline groups of intermediate-acting neuromuscular-blocking agents are appropriate as they do not

Continuous infusions of inotropes and pressors may be needed and must be

Because of surgical handling of the heart, intraoperative arrhythmias are common and should be anticipated. A defibrillator and antiarrhythmic drugs should be immediately available and standard Advanced Cardiac Life Support (ACLS)

Transfusion triggers and the need for intraoperative administration of blood and clotting factors should be discussed and decided by the multidisciplinary team before induction. Ongoing fluid and blood product resuscitation may be required. Adequate haemoglobin levels to ensure optimal oxygen-carrying capacity is needed and should be individualised per case. Peri-operative monitoring of the patient's coagulation status with thromboelastography (TEG) is advised in order to guide targeted administration of plasma products and pharmacological agents that may be required. Because intrinsic myocardial function is generally preserved in pericardial effusion and tamponade, once the tamponade is relieved, there is usually a dramatic improvement in haemodynamics. At this point, vasopressor and inotropic infusions should be reviewed and weaned if appropriate. The use of vasodilator therapy is controversial and only indicated if there is associated systemic hypertension and

Patients should be transferred to a high-dependency unit for continuation of care. Ongoing monitoring is necessary to assess for recurrence of tamponade, ongoing bleeding and continuation of cardiovascular and ventilatory

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support.
