*3.4.1 Causes for effusion*

Causes of pericardial effusion are similar to those for pericarditis and may be due to the inflammatory process itself [6, 16, 18–21]. The most common causes of pericardial effusion seen in the peri-operative period are iatrogenic, associated with cardiac surgery or percutaneous coronary intervention (PCI); traumatic as seen in blunt or penetrating chest injuries; associated with malignancy; as a consequence of end-stage renal disease or dialysis; and those occurring from infectious diseases. In developing countries, especially where the prevalence of HIV is high, tuberculous pericarditis is common [6, 17].

There are a few groups of patients that require special mention as they frequently need intervention by the anaesthesiology team and present with pericardial effusions in the peri-operative period.

#### *3.4.1.1 End-stage renal disease*

Patients with end-stage renal disease (ESRD) frequently present to the anaesthesiologist for a number of diagnostic, therapeutic or vascular access procedures [6, 18–21]. The association with end-stage renal and cardiovascular disease is well established. Increased inflammatory processes, immune and autoimmune dysfunction, dyslipidaemia, endocrine abnormalities, oxidative stress and accumulation of toxic metabolites have all been suggested as causes for this association. This population is known to have an increased incidence of coronary artery disease, valvular pathology, arrhythmias and myocardial and pericardial diseases [18].

**71**

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

efficient dialyzer membranes and methods.

raised intra-pericardial pressure.

syndrome [13, 14, 33].

re-intervention is 1–2.6% [33].

inflammatory response syndrome [32].

The incidence of pericarditis in ESRD is 2–21% with effusion and tamponade being present in up to 14–56% of patients. The aetiology differs between patients on haemodialysis and those who are not. Patients not yet on haemodialysis develop a uraemic pericarditis and effusions that generally respond well to aggressive dialysis and filtration. The incidence of uraemic pericarditis is decreasing because of more

Patients on haemodialysis develop dialysis pericarditis with effusions that more

frequently require drainage via a pericardial window procedure. This group of patients has a higher incidence of progressing to constrictive pericarditis possibly requiring pericardiectomy [18]. Progression from effusion to tamponade may be difficult to diagnose, but progressive right heart failure and hypotension in the setting of adequate diuresis is highly suggestive [18]. All patients with ESRD presenting for surgery should have pre-operative investigations to rule out significant

Indications for drainage of effusions in these patients are based on clinical and biochemical features. Dialysis pericarditis, tachypnoea >20 breaths/min, fever >39°C, low voltage complexes on 12-lead ECG, hypoalbuminaemia <31 g/l, leukocytosis and any signs of tamponade on TTE all indicate the need for drainage [18]. There are little data to support one drainage procedure over another [6, 18]. Pericardiocentesis and pericardial window are both acceptable methods for relief of

Although these patients may exhibit signs of large effusions and even tamponade, significant haemodynamic compromise associated with anaesthesia is rare in this group of patients. Because of the chronicity of the disease process and the associated hypertension, careful titration of agents used for general anaesthesia to

Patients post-cardiac surgery are another group whose management frequently requires the involvement of the anaesthesiology team [24, 32–38]. Accumulation of blood within the pericardial sac because of ongoing bleeding from either a surgical or medical cause peri-operatively will lead to the development of PPE and tamponade. PPE can be divided into early, presenting within 7 days, and late complications occurring more than 7 days post-procedure. An important cause of persistent PPE is the inflammatory response associated with post-cardiac injury

The incidence for PPE has a wide range depending on the study quoted and is approximately 20% on the 20th post-operative day [33]. Most effusions are clinically insignificant, defined as less than 10 mm in diastole on TTE, and resolve spontaneously after reaching their maximum volume on day 10 post-operatively [33]. The incidence of significant pre-tamponade and tamponade requiring

Presenting symptoms are usually non-specific consisting of tachycardia, hypotension, tachypnoea, orthopnoea and decreased heart sounds [24, 32–34]. This low cardiac output state must be differentiated from other common causes of cardiogenic shock in the post-operative period. The differential diagnosis would include hypovolaemia, significant ischaemia, ventricular dysfunction or severe

The following have been identified as independent risk factors for the development of post-operative effusions [33, 34, 37]: heart transplantation, pulmonary thromboembolism, aortic aneurysm surgery, increased body surface area, valve surgery, immunosuppression, urgent or emergent surgery, renal failure and

pericardial disease that may impact on peri-operative management.

facilitate drainage procedures is usually well tolerated [21].

*3.4.1.2 Post-cardiac surgery and post-operative pericardial effusions (PPE)*

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

*Inflammatory Heart Diseases*

**3.3 Chronic pericarditis**

lation within the pericardial sac.

thesia as detailed below.

*3.4.1 Causes for effusion*

pericarditis is common [6, 17].

*3.4.1.1 End-stage renal disease*

effusions in the peri-operative period.

unresponsive to maximal medical therapy [6, 9].

**3.4 Pericardial effusions and tamponade**

obstruction of cardiac filling and tamponade.

parameters.

Chronic pericarditis may be a result of the progression of acute disease or due to recurrent episodes of relapse [6, 9, 10]. The peri-operative management will depend on haemodynamic consequences the disease process has on patient physiological

Differentiation should be made between chronic pericarditis with ongoing inflammation, pain and fever, relapsing disease where patients have periods of being symptom free and chronic pericardial effusion with persistent fluid accumu-

As with acute pericarditis, all elective surgery should be postponed to enable symptomatic treatment of attacks with NSAIDs, colchicine and corticosteroids. Pericardiectomy is indicated in patients with frequent and severe symptoms that are

Chronic inflammatory disease may be associated with a pericardial effusion. Moderate to large effusions, determined at echocardiography as being more than 10 mm separation of the pericardial layers during diastole, should be drained before any elective surgery takes place. Haemodynamic effects of the effusion should be assessed via echocardiographic studies and quantified prior to induction of anaes-

Pericardial effusion occurs when there is excessive fluid accumulation within the pericardial space [3–10, 12, 17–41]. The effusion may be transudative, exudative, haemorrhagic or purulent depending on the cause. Progressive accumulation of fluid within the pericardial sac may lead to compression of cardiac chambers,

Causes of pericardial effusion are similar to those for pericarditis and may be due to the inflammatory process itself [6, 16, 18–21]. The most common causes of pericardial effusion seen in the peri-operative period are iatrogenic, associated with cardiac surgery or percutaneous coronary intervention (PCI); traumatic as seen in blunt or penetrating chest injuries; associated with malignancy; as a consequence of end-stage renal disease or dialysis; and those occurring from infectious diseases. In developing countries, especially where the prevalence of HIV is high, tuberculous

There are a few groups of patients that require special mention as they frequently need intervention by the anaesthesiology team and present with pericardial

Patients with end-stage renal disease (ESRD) frequently present to the anaesthesiologist for a number of diagnostic, therapeutic or vascular access procedures [6, 18–21]. The association with end-stage renal and cardiovascular disease is well established. Increased inflammatory processes, immune and autoimmune dysfunction, dyslipidaemia, endocrine abnormalities, oxidative stress and accumulation of toxic metabolites have all been suggested as causes for this association. This population is known to have an increased incidence of coronary artery disease, valvular

pathology, arrhythmias and myocardial and pericardial diseases [18].

**70**

The incidence of pericarditis in ESRD is 2–21% with effusion and tamponade being present in up to 14–56% of patients. The aetiology differs between patients on haemodialysis and those who are not. Patients not yet on haemodialysis develop a uraemic pericarditis and effusions that generally respond well to aggressive dialysis and filtration. The incidence of uraemic pericarditis is decreasing because of more efficient dialyzer membranes and methods.

Patients on haemodialysis develop dialysis pericarditis with effusions that more frequently require drainage via a pericardial window procedure. This group of patients has a higher incidence of progressing to constrictive pericarditis possibly requiring pericardiectomy [18]. Progression from effusion to tamponade may be difficult to diagnose, but progressive right heart failure and hypotension in the setting of adequate diuresis is highly suggestive [18]. All patients with ESRD presenting for surgery should have pre-operative investigations to rule out significant pericardial disease that may impact on peri-operative management.

Indications for drainage of effusions in these patients are based on clinical and biochemical features. Dialysis pericarditis, tachypnoea >20 breaths/min, fever >39°C, low voltage complexes on 12-lead ECG, hypoalbuminaemia <31 g/l, leukocytosis and any signs of tamponade on TTE all indicate the need for drainage [18]. There are little data to support one drainage procedure over another [6, 18]. Pericardiocentesis and pericardial window are both acceptable methods for relief of raised intra-pericardial pressure.

Although these patients may exhibit signs of large effusions and even tamponade, significant haemodynamic compromise associated with anaesthesia is rare in this group of patients. Because of the chronicity of the disease process and the associated hypertension, careful titration of agents used for general anaesthesia to facilitate drainage procedures is usually well tolerated [21].
