Echocardiography plays a significant role in the diagnosis of pericardial effusion and its related complications. To illustrate this issue, we were involved in the care of a 55-year-old male with liver cirrhosis who presented with pleuritic chest discomfort of four days’ duration. His electrocardiogram (ECG) showed diffuse ST segment elevation and a shortened PR interval (Fig. 1). Echocardiography showed a pericardial effusion of 18–20 mm without compression of the right ventricle but with slight compression of the right atrium. The left ventricular ejection fraction was normal. Initially, he was suspected as having viral pericarditis. However, on the evening of admission, the patient developed hypotension and shock and was transferred to the intensive care unit. Fluid resuscitation was initiated, and broad-spectrum antibiotics and vasopressors were administered. Blood cultures grew coagulase-negative staphylococci.
Over the ensuing days, the patient’s condition deteriorated as he developed progressive respiratory failure, renal failure, and liver dysfunction. Repeat echocardiograms showed persistent pericardial effusion with more significant right atrial compression. A pericardial drain was introduced under echocardiographic guidance, and 500 ml of thick bloody fluid were removed. Vasopressor requirements decreased significantly after the procedure. Pericardial fluid showed numerous polymorphonuclear leukocytes and grew coagulase-negative staphylococci. Despite continued pericardial drainage, the patient’s condition further deteriorated. Based on his moribund condition and poor prognosis, a surgical approach was contraindicated; he died 14 days after admission. Autopsy findings are illustrated in Fig. 2.
Purulent pericarditis is a rare entity that is encountered more often in children and immunocompromised patients.1 Infection of the pericardium occurs via either contiguous infection or hematogenous spread. Staphylococcus aureus is the most frequently encountered organism. The diagnosis is often delayed, as it can only be confirmed by pericardiocentesis, which is most safely accomplished under echocardiographic guidance. Treatment includes intravenous antibiotics and adequate drainage of the pericardium. Reports suggest a role for the infusion of intra-pericardial streptokinase to facilitate drainage, but a thoracotomy with a pericardial window should be attempted if drainage is incomplete. Mortality remains high (40%) even in treated patients.2
Infected pericardial effusion can lead to acute hemodynamic instability through several mechanisms, including obstruction, ventricular dysfunction, and vasoplegia. The most common cause of related hemodynamic instability is obstruction causing tamponade (Fig. 3).3 Tamponade occurs when the pericardial pressure rises above the filling pressure and impairs filling of the ventricles.4 If pericardial fluid accumulates rapidly, a volume as low as 100 ml can lead to tamponade. In contrast, if the fluid accumulates gradually, more than 1 l can be accommodated before the onset of symptoms in adults. In the classical presentation of cardiac tamponade, fluid accumulates across the pericardium. The right atrium, having the lowest pressure, will be the first cardiac chamber to collapse in diastole, followed by the right ventricle and the left atrium in diastole. This can be easily diagnosed using transthoracic (Fig. 4) or transesophageal echocardiography (Fig. 5). After cardiac surgery, however, localized tamponade can occur with regional compression of any of the cardiac chambers. In that situation, transesophageal echocardiography is mandatory to rule out the diagnosis (Figs. 6, 7). As tamponade progresses and shock worsens, coronary perfusion pressure is compromised leading to additional myocardial dysfunction.6 Less frequently, and as illustrated in this case, pericardial effusions can be a source of sepsis in patients with fever of unknown origin. In patients with tamponade, venous return will be maintained as long as mean systemic pressure (Pms) is maintained. Therefore, volume expansion and vasopressors such as noradrenaline and phenylephrine can be used. Inotropes can also be used to lower right atrial pressure; however, they can reduce Pms and worsen the condition. The definitive treatment of tamponade is the reduction of the surrounding pressure either percutaneously or surgically. Our approach to the diagnosis and management of pericardial effusion and tamponade is summarized in Fig. 8.
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Durand, M., Lamarche, Y. & Denault, A. Pericardial tamponade. Can J Anesth/J Can Anesth 56, 443–448 (2009) doi:10.1007/s12630-009-9080-3
- Pericardial Effusion
- Transesophageal Echocardiography
- Cardiac Tamponade