Pericardial effusion—A life saver!

HE USE OF interventional cardiac catheterization in children with congenital cardiac defects has grown dramatically in the last two decades, comprising more than 40% of all catheterizations in children and posing a new challenging environment for the anesthesiologist.l Two cases are reported to present the role of the anesthesiologist during pediatric cardiac catheter interventions and to emphasize the impact of collaborative efforts of the cardiologist and the anesthesiologist on patient outcome. CASE 1 A 3-day-old male neonate, weighing 3.5 kg, was born at 41 weeks gestation through normal vaginal delivery. At birth, the baby had low Apgar scores and, despite multiple resuscitation maneuvers, continued to be increasingly cyanotic. A transthoracic echocardiogram showed severe hypoplasia of the left ventricle and the ascending aorta, with mitral atresia, a patent ductus arteriosus, and a restrictive atrial septal defect. He was started on a prostaglandin E1 infusion, 50 ng/kg/min, and taken to the pediatric cardiac catheterization laboratory for a balloon atrial septostomy to improve intracardiac mixing. After induction with 2 mg/kg of ketamine intravenously, the airway was secured using a 3.5-ram internal diameter endotracheal tube, and a fight radial arterial catheter was placed. Through a 6F right femoral venous sheath, a 5F Numed Balloon Septostomy catheter (Braun, Inc, Bethlehem, PA) was introduced, advanced across the atrial septal defect, and the balloon was inflated to its 2-mL capacity. On withdrawal of the inflated balloon to enlarge the septal defect, the baby became progressively hypotensive and bradycardic. A transthoracic echocardiogram showed a rapidly accumulating pericardial effusion with marked cardiac compression (Fig 1). Immediate cardiopulmonary resuscitation was started, with closed-chest massage and multiple doses of epinephrine, 10 ~tg/kg, while awaiting the arrival of blood products and a cardiac surgeon. The cardiologist placed a 20-G catheter into the pericardial space through the subxiphoid approach and, using intravenous tubing, a three-way stopcock, a 170-pro filter, and a male-to-male adapter, the anesthesiologist was able to continually withdraw blood from the pericardial sac and retransfuse it to the patient through a peripheral intravenous line (Fig 2), thus maintaining hemodynamic stability by reinfusion of 60 mL of blood to the patient. The cardiac surgeon was able to perform a sternotomy, evacuate the pericardium, and identify a tear at the upper pole of the right atrium, which he successfully repaired. The baby was taken to the pediatric intensive care unit in stable condition and had an uneventful stage I Norwood repair 2 days later. CASE 2 A 13-year-old, 31-kg boy with a history of truncus arteriosus, repaired at 3 months of age, with a revision of the pulmonary artery homograft at the age of 5 years, presented to the cardiac catheterization laboratory with a calcified pulmonary artery homograft, a stenosed right pulmonary artery (Fig 3), and right ventricular hypertension (right ventricular systolic pressure, 95 mmHg). He was scheduled for stenting of the right pulmonary artery and possible balloon dilatation of the calcified homograft.