1. Pericardial effusion R2 鄭淳心

2. Name: 楊許 X 玉 Chart no.:3230708 Sex: female Age:78y/o Birthday: 13/02/17 Weight: 80Kg Admitted to ER due to falling down with head injury, no loss of conscious, no syncope. Chest tightness, cold sweating, drowsy conc. BP: 87/35mmHg, T 34.4,Rate 54, sugar 367 Lethargy, extremity :edema

3. Past history: 1. GB stone s/p op 2. S/p appendectomy 3. colon valvulous s/p 4. CAD with AMI history (?) 5. HTN(+), DM(-)

4. Brain CT: chronic SDH with old lacunar infraction Chest X-ray: widen mediastenum with double line of aorta Chest CT scan: ascending aorta D=5cm, pericardial effusion 1cm thick, suspect: Intramural hematoma on ascending aorta arch and descending aorta with marked trachea deviation

5. Cardiac echo: pericardial effusion with tamponade sign severe AR, Dilated aortic root, fair heart contractility BP 105/73 under Dopamine 40ml/hr (13ug/kg/min) Impression : 1.pericardial effusion with tamponade 2. Ascending aortic aneurysm with suspect intramural hematoma

6. Pericardial effusion Associated with Chest trauma Cardiac or thoracic surgery Pericardial tumor Pericarditis (acute viral, pyogenic uremic, or postradiation ) Myocardial perforation by a central venous or pulmonary artery catheter Aortic dissection

7. Pericardial effusion Clinical feature: Tachycardia Hypotension Jugular venous distention Muffled heart sound ECG: electrical alternans Pulsus paradoxus

8. Pericardial effusion Equalization of right- and left-side heart pressure CVP=RVEDP=PWCP Definitive diagnosis Cardiac echocardiography Tamponade physiology:cardiac catheterization

9. Pulsus paradoxus Seen in Cardiac tampomade Severe COPD Asthma Pulmonary embolism

10. Pulsus paradoxus Absent in cardiac temponade p ’ t with coexistent cardiac pathology ASD, LVH, LV failure, infraction, ischemia, or aortic valve incompetence

11. Pericardial effusion Blind drainage complication Peumothroax Coronary a. or internal mammary a. laceration Ventricular chamber perforation

12. Pericardial effusion Anesthetic goals 1. In cases of tamponade, relieve the restriction to diastolic filling before the induciton 2. Avoid postive pressure ventilation until tamponade physiology has been relieved 3. Maintain filling pressure high enough 4. Avoid vasodilation 5. Avoid bradycardia 6. If compromised, support myocardial contractility

13. Pericardial effusion PRE-induction Effusion status Past history with impairment contractility, prepare inotrope agent infusion Alpha-adreneric support may be needed Heart rate must be maintained A-line, 5-lead EKG Large-bore iv (14# 0r 16#) CVP, PA-catheter Prepare for emergency incision before induction

14. Pericardial effusion Induction Etomidate 0.3mg/kg Fentanyl 5 to 10 ug/kg Ketamine 1 to 2 mg/kg iv Amnesia: use BZD or inhalation agent Muscle relaxant: pancuronium Keep SVR, heart rate, contractility

15. Pericardial effusion TEE S/p drainage : pul. venous cogestion or pul. edema endotracheal tube Breathing :spontaneous or ventilated Attention for ventricular filling pressure and intravascular volume

16. Thank you for your attention!!!