Pericardial

Question 1

What is the pericardium

Answer 1

The pericardium is a sac surrounding the heart.

1. Two tissue layers:
   
   • Visceral, a thin tissue-like layer
   • Parietal, a more fibrous, rigid layer
2. Pericardial cavity
   
   • holds 20 – 50 ml of pericardial fluid.

Pericardial pressure is similar to pleural pressure varying with respiration between –4 mm Hg and +4 mm Hg.

Question 2

Pericardium function

Answer 2

1. Prevents infection
2. Lubricates the heart
3. Facilitates motion within the sac
4. Protects the heart from excessive displacement
   
   • maintains optimum shape of the heart
5. Applies a compensatory hydrostatic pressure to the heart
   
   • to compensate for alterations in gravitational force

Question 3

Acute pericarditis

what is it

what are the causes

Answer 3

Inflammation of the pericardium

Causes:

• infection
  
  • viral
  • bacterial
  • fungal
  • tuberculous
• myocardial infarction
• trauma/cardiotomy
• metastatic disease
• drugs
• mediastinal radiation
• systemic diseases:
  
  • Rheumatoid Artheritis
  • Lupus
  • Scleroderma

Question 4

Acute Pericarditis - diagnosis

Answer 4

1. Sudden onset of severe chest pain exaggerated by inspiration
2. Diffuse ST segment elevation, PR segment depression, T wave inversion
3. Pericardial friction rub

Question 5

Acute Pericarditis - treatment

Answer 5

Treatment:

1. Salicylates or NSAIDS
2. Analgesics (Indomethacin)
3. Corticosteroids

Acute pericarditis in the absence of effusion does not alter cardiac function.

Question 6

Pericardial Effusion

what is it

causes

diagnosis

Answer 6

• Accumulation of pericardial fluid in the pericardial cavity
• Causes:
  
  • Idiopathic-unknown cause
  • Neoplastic
• Diagnosis
  
  • ECHO - the most useful method for clinical detection of effusion – it is very accurate on estimating effusion size
  • Signs and symptoms depend on the rate of fluid accumulation
    
    • Acute: _{with an rapid effusion, the pericardium does not have time to accommodate, so intrapericardial pressures increase significantly and cardiac tamponade results - Even small volumes of fluid (100 – 200 ml) that accumulate rapidly will cause cardiac tamponade}
    • Gradual: _{if the effusion develops gradually, the pericardium stretches to accommodate fluid - A large volume of fluid (up to 1000 ml) can accumulate without a significant increase in pressure}

Question 7

Cardiac Tamponade

What is it

Answer 7

• Cardiac tamponade exists when an increase in pericardial pressure impairs diastolic filling of the heart.
• Cardiac filling is related to the diastolic transmural (distending) pressure across each chamber
  
  • _{Transmural pressure = Pressure within the chamber - extracavity pericardial pressure}
  • _{Any increase in pericardial pressure relative to the pressure within the chamber reduces filling}
• Medical Emergency

Question 8

Cardiac Tamponade

Signs and Symptoms

Answer 8

1. Increased central venous pressure
2. Pulsus paradoxus
3. Equalization of cardiac filling pressures
4. Hypotension
5. Decreased CO, SV
6. Decreased voltage on ECG
7. Activation of the SNS
8. Tachypnea
9. JVD
10. Muffled heart sounds

Question 9

Cardiac Tamponade

Treatment

Answer 9

removal of fluid

• Pericardiocentesis
• Subxiphod pericardiostomy
• Thoracic pericardiostomy (open or thoroscopic)

Question 10

Cardiac Tamponade

Anesthetic Management

Answer 10

• Expand intravascular volume
• Increase myocardial contractility
  
  • Isoproterenol
• Correct metabolic acidosis
• Can do under local, or with Ketamine

Question 11

Constrictive Pericarditis

What is it

Causes

Answer 11

Fibrous scarring and adhesions of the pericardial cavity that creating a rigid, stiff shell around heart that limits filling of the heart

Causes

• Idiopathic
• Previous cardiac surgery
• Exposure to radiotherapy
• TB

Question 12

Constrictive Pericarditis sxs

Answer 12

• CVP, RAP, PCWP elevated
• CO decreased
• Fatigue
• Atrial dysrhythmias
• Edema
• Ascites
• Hepatomegaly
• Pulsus paradoxus
• JVD

Question 13

Constrictive Pericarditis - treatment

Answer 13

Surgical stripping and removal of adherent constricting pericardium (pericardiectomy)

Question 14

Constrictive Pericarditis - anesthetic management

Answer 14

1. Minimize changes to HR, SVR, preload, and contractility
   
   • _{use: ketamine, etomidate, pancuronium}
2. Avoid bradycardia
3. Maintain intravascular volume to avoid hypotension
   
   • _{have large bore IV’s, A-line}
4. Blood transfusions may be necessary to treat blood losses associated with pericardiectomy