110 ANESTHESIA . . Currerit Reseurclles VOL. 52, No. 1, JAN.-FISB.

,
AND ANALGESIA. 1973

Anesthesia for the Patient with Cardiac Tamponade

THEODORE H. STANLEY, MAJOR, USAF (MC)

HARVEY E. WEIDAUER, CAPTAIN, USAF (MC)
Lackland Air Force Base, Texas*

M OST patients with cardiac tamponade

are treated outside of the operating
room with needle aspiration.' Occasionally
tamponade can be effectively treated only
by open drainage, or repair and/or resection
of the pericardium or its contents and anes-
thetic support is needed."-l General anes-
thesia in these patients, however, is fre-
quently associated with severe hypotension
and cardiac arrest."."-D All general anesthet-
ics are myocardial depressants1"-12and most
are peripheral vasodilators.13-18Since car-
diac tamponade is characterized by im-
paired cardiac filling and a reduced cardiac
o u t p u t , hemodynamic decom pensa t ion
should not be unexpected with general anes-
thesia in these patients. To avoid this, we
now use local infiltration anesthesia for all
patients coming to the operating room for
decompression of pericardial effusions. The
following two cases document the speed,
ease, and safety of using local anesthesia for
these procedures.
REPORT OF CASES
Case 1.-A 67-year-old Caucasian man
was admitted to the hospital because of in-
creasing shortness of breath and loss of 45
pounds over a 4-month period. The short-
ness of breath occurred with exercise and at
night. It was associated with epigastric full-
ness and tightness, but not with pain or
radiation. Relief was obtained only by sit-
ting upright for 3 to 5 minutes.
Past medical history included hyperten-
sion, an upper gastrointestinal hemorrhage,
and emphysema, which were being treated
with methyldopa, cyclandelate, and inter-
mittent positive-pressure breathing with iso-
proterenol, respectively.
On admission, the patient's temperature
was 98.8" F., pulse rate 96/min., respiration
20/min., and blood pressure 160/110 mm.
Hg. On physical examination the chest was
clear to auscultation and percussion. The

"Anesthesiology Service. Wilford Hall USAF Medical Center (AFSC), Lackland Air Force Base, Texas
78236.
Dr. Stanley's current address: University of Utah Medical Center, Division of Anesthesiology, Salt Lake
City, Utah 84112.
Anesthesia and Cardiac Tamponade . . . Stanley and Weidauer 111

heart was percussed to the anterior axillary
line at the fifth rib; heart sounds were dis-
tant, and the rate was irregular at times.
A fourth heart sound was present at the
apex, but no third sound was heard. A posi-
tive Kussmauls sign was elicited. Abdomi-
nal examination was negative, except for
splenomegaly of 3+ on a basis of 1 to 4.
The extremities were not edematous.
Chest x-rays showed a diffusely enlarged
cardiac silhouette. The lungs were clear, and
the pulmonary vasculature normal. An elec-
trocardiogram showed diffuse flattening of
all T waves. In addition, S-wave depression
and T-wave inversion were seen in leads V,
and V,;. This finding was compatible with
the presence of pericarditis. Cardiac cathe-
terization revealed a mean right atrial pres-
sure of 12 mm. Hg, and separation of the
dye in the right atrium by 2 to 3 cm. from
the right heart silhouette. Other preopera-
tive diagnostic procedures, including sig-
moidoscopy, liver scan, bone marrow biopsy,
renal tomogram, abdominal aortogram, and
renal arteriogram, disclosed only normal
conditions.
A diagnosis of pericardial effusion and
tamponade was made. Two attempts a t peri-
cardiocentesis were unsuccessful, and open
pericardial drainage was deemed necessary
to relieve the effusion.
The patient was taken to the operating
room without any premedication. With con-
tinuous electrocardiographic monitoring and
administration of oxygen by mask ( 5 L./
min.), a total of 20 ml. of 1 percent lido-
caine was used to infiltrate the skin, subcu-
taneous tissues, rectus abdominis muscle,
perichondrium, and periostium about the
xiphisternal junction. A 3-inch vertical mid-
line incision was made down to the xiphoid
process. The xiphoid process was then ex-
cised to expose the anterior portion of the
diaphragm and the pericardium and a 2 cm.
square window was excised in the pericar-
dium which allowed removal of 1700 ml. of
pericardial fluid. T h e blood pressure
changed immediately from 116/90 mm. Hg
to 146/96 mm. Hg. The wound was closed,
and the patient was returned to the ward.
The patient was discharged 10 days later
and he was then completely free of all
symptoms.
Case 2.-A 50-year-old Caucasian man
was admitted 1% hours after receiving stab
wounds in the left side of chest and right
upper part of the abdomen. On admission
to the emergency room, physical examina-
tion revealed an alert but anxious middle-
aged man with pulsating, distended neck
veins, rapid and weak peripheral pulses
( 120/min.), and no detectable blood pres-
sure.
Intravenous administration of Ringers
lactate solution was started in a hand vein
through a 16-gauge line and the patient was
immediately taken to the operating room
with the diagnosis of acute tamponade.
There was no time to take a chest x-ray,
standard electrocardiogram, or insert a cen-
tral venous pressure line. While the patient
was being prepared for surgery, blood was
drawn for typing and crossmatching. With
continuous electrocardiographic monitoring
and administration of oxygen by mask ( 5
L./min.) a total of 25 ml. of 1 percent solu-
tion of lidocaine was used to infiltrate the
presternal skin and subcutaneous tissues
from the manubrium to the xiphoid process.
Within 15 minutes of admission to the emer-
gency room a complete sternotomy had been
accomplished and a pericardial window
opened that allowed removal of 350 ml. of
unclotted blood. The blood pressure, which

* THEOD~RE H. STANLEY, M.D., received his medical

education at Columbia University, College of Physicians
and Surgeons in New York City. After completing his
internship at the University of Michigan Hospitals in
Ann Arbor, Dr. Stanley returned to Columbia University
for his Residency in Anesthesiology. Artificial organs are
Dr. Stanleys primary research interest and he was the
recipient of the Deans award of the University of Michi-
gan to study the means to develop an artificial heart and
has several publications encompassing this field.
112 ANESTHESIA . . Current Researches VOL.52, No. 1, JAN.-FEB.,
AND ANALGESIA.
had not been obtainable up to this time, sud-
denly was detected and was measured at
110/70 mm. Hg. The pulse rate slowed to
94lmin.
Following release of the tamponade and
with a detectable blood pressure and strong
pulse, rapid induction of anesthesia and in-
tubation were accomplished without difficul-
ty with 150 mg. of thiopental and 80 mg. of
succinylcholine given intravenously. After
intubation, the blood pressure was 120186
mm. Hg, and the pulse rate 100Imin. Halo-
thane-nitrous oxide-oxygen anesthesia was
started, and the surgeons ligated several
bleeding vessels on the epicardial surface
of the heart. Following ciosure of the ster-
num, exploratory laparotomy was performed
and a lacerated liver was successfully re-
paired.
General anesthesia lasted nearly 4 hours.
The vital signs remained stable a t all times
during the procedure. Systolic blood pres-
sures ranged between 90 and 120 mm. Hg,
and pulse rates between 70 and 94fmin.
The patient was awakened and extubated
at the end of the procedure. He made an
uneventful recovery and was discharged
from the hospital 3 weeks later.
DISCUSSION
Pericardial effusions result from both
acute and chronic diseases that involve the
pericardium. The most detrimental effect of
these accumulations, cardiac tamponade,
occurs when the effusions exist in sufficient
volume to impede myocardial filling. Since
cardiac output in these patients is reduced
and fixed and is dependent on an elevated
venous filling pressure, anything that im-
pairs cardiilc contraction or venous return
will further reduce output. As these patients
may also be peripherally constricted before
anesthesia, the result of any additional de-
crease in output is frequently hypotension.
Although patients with fulminant acute
tamponade have the greatest interference in
circulation, even the well-compensated pa-
tient with tamponade is a t great risk should
his venous return be reduced or his myo-
cardium be even slightly compromised. This
was well documented by Murray and Ro-
bertson'!' in two patients with unsuspected
tamponade who were anesthetized with low
concentrations of nitrous oxide and halo-
thane. The resulting hypotension in both
these patients was unresponsive to rapid in-
1973
travenous administration of fluid, termina-
tion of anesthesia, and the usual vasopres-
sors. It was only corrected by releasing the
effusions. Similarly, hypotension and car-
diac arrest have been reported in patients
with tamponade after administration of thio-
pental, d-tubocurarine, atropine, most gen-
eral anesthetics, and even preoperative se-
dation.?,~-!l,l"l',2U
All inhalation and most intravenous anes-
thetics d e c r e a s e m y oca r d i a 1 contractil-
ity. l o - z , 1 T , 2 All except light concentrations
of cyclopropane, ether, and possibly keta-
mine are peripheral vasodilators.l"-'Rp"Jz
The exceptions presumably are agents that
maintain vascular tone and venous return
by stimulating the release or preventing the
uptake of norepinephrine.21-24Since the pa-
tient in tamponade may be under the effects
of maximum e n d og e n ou s catecholamine
stimulation before induction of anesthesia,
even these agents may result in vasodilata-
tion and a reduced venous return.
Arrhythmias are common in patients with
tamponade.Iqu T o prevent arrhythmias, even
minimal degrees of hypoxia and hypercarbia
should be avoided. For this reason con-
trolled ventilation is a n essential part of the
general anesthetic technic for these patients.
Yet, intermittent positive-pressure breath-
ing may cause further tamponade of the
heart, lungs, and intrathoracic great veins.?;
Mushin,2Gin fact, suggests that this may be
a major cause of hypotension in the anes-
thetized patient with tamponade.
To avoid general anesthesia and its prob-
lems in this disease, we began using local
infiltration anesthesia routinely for all pa-
tients with tamponade coming to the operat-
ing room for any operative procedure other
than needle aspiration. The patients receive
no premedication or intraoperative sedation
but are given oxygen to breathe with a face
mask. With routine vital sign (cuff blood
pressure, pulse, and respiratory rate) and
electrocardiographic monitoring, local infil-
tration anesthesia is accomplished (usually
with 1 to 1.5 percent solution of lidocaine),
a s u b x i p h o i d (extrathoracic) pericardial
window is created27 as described in case 1,
and the effused fluid is removed within 15
to 20 minutes. Bleeding vessels are usually
easily ligated, but if better exposure is nec-
essary, the sternum can be partially or total-
ly split with the use of less than a total of
30 ml. of a local anesthetic. More extensive
surgery, or opening the pleural cavities, or
both require intermittent positive-pressure
Anesthesia and Cardiac Tamponade . . . Stanley and Weidauer
ventilation and general anesthesia. This,
however, is used only after the tamponade
has been released. At that time general an-
esthesia can be carefully and safely induced.
A total of 16 patients with both acute and
chronic tamponade have been anesthetized
in this fashion at our institution since Sep-
tember 1969. About 30 percent have under-
gone general anesthesia for additional sur-
gery after the tamponade has been released.
There have been no hypotensive episodes,
cardiac arrests, or deaths in the operating
room or in the immediate postoperative pe-
riod. We suggest, therefore, that this tech-
nic is safer than even the most carefully ad-
ministered general anesthetic and that it
should be adopted for all patients with car-
diac tamponade coming to surgery.
SUMMARY
A technic combining local infiltration and
general endotracheal anesthesia is described
to prevent the severe hypotension and car-
diac arrest so frequently associated with
general anesthesia during operative correc-
tion of cardiac tamponade. After using local
anesthesia to infiltrate the skin, subcutane-
ous tissues, rectus abdominis muscle and
perichondrium about the xiphisternal junc-
tion an incision is made down to and then
into the pericardium relieving the tampon-
ade. If more extensive surgery or opening
the pleural cavities is necessary, then and
only then is general anesthesia induced, the
patient intubated, and the surgical proce-
dure allowed to continue. Of the 16 patients
anesthetized in this fashion since 1969, 30
percent have undergone general anesthesia
for additional surgery after the tamponade
has been released. There have been no hypo-
tensive episodes, cardiac arrests or deaths
in the operating room or immediate post-
operative period. This technic appears to
be safer than even the most carefully ad-
ministered general anesthetic in these pa-
tients.
Generic and Trade Names of Drugs
Lidocaine-Xylocaine
Halothane-Fluothane
Methyldopa-Aldomet
Cyclandelate-Cyclospasmal
Isoproterenol-Isuprel
Sodium thiopental-Pentothale Sodium
Succinylcholine-Anectine
Ketaminc-Ketalar, Ketaject
d-Tubocurarine-Tubarine
113
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AND ANALGESIA.
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While your friend holds you affectionately b y both your hands you a r e safe, f o r
you can watch both his.
* *
When fortune smiles, w h a t need of friends ?
* *
A friend is a person who knows all about you-and
23. Price HL, Linde HW, Jones RE, et al: Sym-
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20:563-575, 1959
24. Jones ER, Linde HW, Deitsch S, et al:
Hemodynamic actions of diethyl ether in normal
man. Anesthesiology 23:299-305, 1962
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27. Fontenelle LJ, Cuello L, Cooley BN: Subxi-
phoid pericardial window. J Thorac Cardiovasc Surg
62: 95-97, 1971
-Ambrose Bicscc
*
-E u r i p id cs
*
still likes you.
-Elbert Hubbartl