Joshua S. Newman, MD, MS and Frank Manetta MD
Northwell Health, Manhasset, NY, USA
Essential Operative Steps
- Invasive lines and monitors
- General endotracheal anesthesia vs monitored anesthesia care
- Transesophageal echocardiography to assess effusion
- Transthoracic echocardiography to assess effusion location/incision planning
- Subxiphoid skin incision with or without resection of the xiphoid process
- Pericardiotomy
- Evacuation of pericardial effusion/relief of cardiac tamponade
- Chest tube placement
- Skin closure
Potential Complications / Pitfalls
- Hemodynamic instability precluding intubation for patients in severe cardiac tamponade. Procedure may be started with
awake draping and local anesthesia to avoid the myocardial depressive effects of general anesthesia. Once the tamponade
is relieved, the patient may be rapidly intubated and placed under general anesthesia as support requirements improve - Pericardiotomy should be done without electrocautery to avoid risk of fibrillation. Utilization of Metzenbaum scissors
with downward traction on the pericardium allows for safe entry without the risk of fibrillation from cautery contact with
myocardium - Injury to the diaphragmatic surface of the right ventricle. Pericardiotomy should be done under gentle downward traction
to avoid injury to the diaphragmatic RV in acute, small effusions
Template Dictation
Preoperative Diagnosis: Pericardial effusion
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed: Subxiphoid drainage of pericardial effusion
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] old [SEX] with a history of [BLANK] who presented with [BLANK] and was found to
have a pericardial effusion [with/without] clinical and echocardiographic evidence of cardiac tamponade. The procedure was
completed for diagnostic and therapeutic purposes.
Findings: Approximately [volume of effusion] [quality of effusion] effusion was evacuated from the pericardium. The patient
was [hemodynamically stable throughout the case / the patient was initially hemodynamically unstable and after
evacuation of effusion the patient had rapidly decreasing support requirements and return of hemodynamic stability].
Description of the Procedure: The patient was identified, brought to the operating room, and placed in the supine position.
A [radial/femoral] arterial line and standard invasive lines and monitors were placed, and the patient was induced under
general anesthesia. A full sternotomy preparation was performed, and the patient was draped in the usual fashion. [Note: If the
patient is too unstable for general anesthesia: Because the patient was unstable secondary to cardiac tamponade, the patient
was prepped and draped while awake prior to induction of general anesthesia].
An incision was made overlying the xiphoid process in the midline extending to approximately 2cm inferior to the xiphoid
process. The xiphoid process was identified. An army-navy retractor was placed under the xiphoid process. With cephalad
retraction, the diaphragmatic attachments to the posterior xiphoid were freed bluntly and with electrocautery. The pericardium
was identified. An area on the diaphragmatic pericardium was cleared with a long peanut and the pericardium was grasped
with an Allis clamp and sharply opened with a scissor. [Quality of effusion] was encountered and [quantity of effusion] was
evacuated. The effusion was drained completely, and this was confirmed with intraoperative TEE. The fluid and pericardium
were sent for microbiology, cytology, and pathology.
A separate stab incision was created inferior to the operative incision and a 12Fr Blake channel drain was tunneled and placed
in the dependent portion of the pericardium and sutured in place using a 2-0 nylon suture. The wound was closed in layers,
utilizing a 2-0 vicryl for the facial/subcutaneous layer, 3-0 vicryl for the deep dermal, and 4-0 monocryl for the subcuticular
approximation.
The patient was extubated in the operating room. There were no complications, and all counts were reported as correct.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
Figure 1: Computed tomography demonstrating pericardial effusion in the coronal and axial views
Multiple Choice Question(s)
Which of the following findings are expected to be present in a patient experiencing cardiac tamponade physiology?
A. Reduced cardiac index
B. Elevated intracardiac filling pressures
C. Pulsus paradoxus
D. Presence of a “square-root sign” on invasive pressure monitoring
E. A, B and C
F. All of the above
Answer: E. Cardiac tamponade causes equalization of pressures in the chambers of the heart and decreased intracardiac filling
secondary to an increased intrapericardial pressure. The cardiac index may be initially maintained by catecholaminergic support
but will eventually decline. The intracardiac filling pressures are elevated to overcome the increased external force of the
elevated pericardial pressures. Pulsus paradoxus is experienced and is a fall of greater than 10mmHg in systolic blood pressure
with inspiration. The square-root sign (ventricular filling during diastole that plateaus when the RV reaches a critical volume)
is present on invasive monitoring in patients with constrictive pericarditis and less commonly restrictive cardiomyopathy.
Sources
Feins EN, Walker JD. Pericardial Disease. In: Cohn LH, Adams DH. eds. Cardiac Surgery in the Adult, 5e. McGraw Hill;
Accessed February 20, 2022. https://accesssurgery.mhmedical.com/content.aspx?bookid=2157§ionid=164306252
