| Abstract|| |
Pericardial tamponade limits diastolic filling of the heart; therefore, a high venous pressure is required to fill the ventricle. In presence of cardiac tamponade, therapeutic agents and manoeuvres that results in venodilation or vasodilation can severely compromise diastolic filling of the heart and might result in rapid cardiac decompensation. Equalization of central venous pressure and pulmonary artery diastolic pressure or equalization of pressures in all four chambers during diastole confirms cardiac tamponade. Transthoracic echocardiography can detect the site of tamponade and assist in pericardiocentesis. We describe acute pericardial tamponade in a young man who underwent left posterolateral thoracotomy for left upper lobectomy. Intraoperatively, mobilization of the left upper lobe was frequently associated with hypotension. Postoperatively, the patient suffered two more episodes of hypotension. The episodes of hypotension were attributed to surgical manipulation and epidural blockade. Hemodynamics normalized after discontinuing epidural infusion, volume resuscitation and lobectomy. On third postoperative day, the patient developed cardiovascular collapse; arterial blood pressure and central venous pressure were 70/50 and 12 mmHg. Investigations showed haziness of left lung, and severe respiratory acidosis. On opening of the left thoracotomy wound, pericardial tamponade was diagnosed. A pericardial window was created and tamponade was released with that the hemodynamics normalized. Episodes of unexplained hypotension after left upper lobectomy suggest a cardiac etiology and acute pericardial tamponade is a possibility which should be released immediately otherwise it can result in fatal outcome.
Keywords: Aspergilloma, left thoracotomy, left upper lobectomy, pericardial tamponade
|How to cite this article:|
Neema PK, Shah H, Sethuraman M, Rathod RC. Pericardial tamponade after left posterolateral thoracotomy for left upper lobectomy for pulmonary aspergilloma. Ann Card Anaesth 2011;14:111-4
|How to cite this URL:|
Neema PK, Shah H, Sethuraman M, Rathod RC. Pericardial tamponade after left posterolateral thoracotomy for left upper lobectomy for pulmonary aspergilloma. Ann Card Anaesth [serial online] 2011 [cited 2020 Mar 28];14:111-4. Available from: http://www.annals.in/text.asp?2011/14/2/111/81565
| Introduction|| |
The major postoperative complications following lung resection include pulmonary insufficiency, residual intrapleural air space, arrhythmias, cardiac herniation, lobar gangrene, prolonged air-leak, bronchopleural fistula, esophageal fistula, pulmonary embolism, tumor embolism and post pneumonectomy empyema.  The reported postoperative complications of pulmonary aspergilloma are major bleeding, prolonged air-leak, empyema, pneumothorax and wound dehiscence.  The majority of complications occur during first two postoperative days.  Iatrogenic cardiac and pericardial injuries during surgery are known.  We report cardiac tamponade on third day after left upper lobectomy for pulmonary aspergilloma and discuss pathophysiology of the clinical presentation.
| Case Report|| |
A 28-year-old well-built young man (height 6 feet 1 inch, weight 79 kg) presented with dry cough, low-grade fever, and occasional hemoptysis. The patient had received full course of antitubercular drugs. On examination, his pulse rate and blood pressure were 80/min and 136/80 mmHg. On chest auscultation, air-entry over left chest was diminished. CT chest scanogram [Figure 1] showed opacity in left upper lobe (LUL) with normal cardiac silhouette. CT scan of thorax showed left upper lobe cavitatory lesion (aspergilloma). Laboratory test results and pulmonary function tests were normal. The patient underwent left posterolateral thoracotomy for LUL excision.
Patient premedicated with inj morphine 5 mg and glycopyrrolate 0.2 mg. Anesthesia was induced with thiopentone sodium 400 mg and fentanyl 200 μg; and pancuronium 8 mg was administered to facilitate insertion of a left sided 39F double lumen endobronchial tube (DLT; Mallinckrodt Medical Cornamaddy Athlone Co, Westmeath, Ireland). The position of DLT was confirmed by chest auscultation and fibreoptic bronchoscopy. Anesthesia was maintained with N2O in O2 (40:60) and isoflurane (1-2%). A 7F triple lumen catheter was placed in the right internal jugular vein without difficulty. An epidural catheter was inserted in seventh intervertebral space and a 10 ml bolus of bupivacaine 0.125% was administered, followed by its infusion at 5 ml/h. Monitoring included ECG, heart-rate, SpO 2 , EtCO 2 , and direct arterial and central venous pressures (ABP and CVP) and arterial blood gas (ABG) analysis. One-lung ventilation was provided during LUL dissection; the lung isolation was adequate. The mobilization of the LUL was associated with multiple episodes of hypotension (Systolic ABP 50-60 mmHg). Epidural bupivacaine infusion was discontinued and patient was resuscitated with 1500 ml pentastarch. The CVP during episodes of hypotension remained at 6-10 mmHg. Hemodynamics stabilized after lobectomy. At the end of surgery, the DLT was changed to 9 mm portex endotracheal tube.
In the intensive care unit (ICU), after 1 h of elective ventilation, trachea was extubated and epidural infusion of bupivacaine 0.125% was restarted at 5 ml/h. Postextubation ABG and chest X-ray were satisfactory. After 4 h, epidural bupivacaine infusion was discontinued because of two episodes of hypotension (Systolic ABP 80-90 mmHg). Thereafter, he remained hemodynamically stable. On postoperative day (POD) one, the patient was transferred to surgical ward. On POD 2, the patient complained uneasiness after mild exertion and became tachypnic (respiratory rate 32-36/min); the ABP and pulse-rate were 110/86 mmHg and 120 per min. Oxygen 6 l/min was started and midazolam 5 mg was administered for sedation; however, the patient became agitated, the respiratory rate further increased, the extremities became cold, the peripheral pulses became impalpable and the SpO 2 showed no plethysmograph. The patient was transferred to the ICU; invasive monitoring showed ABP and CVP 70/40 and 12 mmHg, respectively. To support circulation, epinephrine infusion 0.1-μg/kg/min, volume resuscitation, and elective ventilation were started. ABG showed hypoxemia and severe respiratory acidosis. Chest X-ray showed haziness in left lower zone and suspicion of cardiomegaly [Figure 2]. Catheterization showed no urine. Rotation of left lower lobe was suspected. While CT scan and transthoracic echocardiography were arranged, the patient further deteriorated; he was immediately shifted to operating room with a heart-rate of 150/min, ABP 60/45 mmHg, and CVP 12 mmHg. On reopening the left thoracotomy wound, the left lower lobe was ventilating normally, and no fluid or collected blood was found in the thorax. However, the pericardium showed reddish discoloration and was bulging. A pericardial window was created and about 200 ml sanguinous fluid drained, the hemodynamics improved immediately. Further examination revealed a hematoma around an epicardial vein and an injury mark on the adjacent pericardium. After removing hematoma and ensuring hemostasis, the pericardium and chest were closed and the patient was returned to ICU. On regaining consciousness, the trachea was extubated. Remaining postoperative course of the patient was uneventful.
|Figure 2: Chest X-ray (A-P view) showing haziness of left hemithorax and suspicion of cardiomegaly|
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| Discussion|| |
The complications following pulmonary resection have decreased remarkably due to refinements in anesthesia, surgical techniques, and postoperative care. A review of complications of surgery in treatment of lung carcinoma revealed 8% minor and 9% major but nonfatal complications.  The majority of serious complications were cardiorespiratory. Intraoperative complications in patients undergoing lung resection were related to surgical dissection and include hemorrhage, nerve injuries, and systemic tumor embolism. Intraoperative pericardial tamponade has been reported because of central venous cannulation;  and because of retraction of transected inferior pulmonary vein into the pericardial sac during left lower lobectomy.  Levitt et al, reported intraoperative pericardial tamponade in a patient undergoing esophagogastrectomy, possibly due to inadvertent injury to an epicardial vein. 
In the present patient, the cause of pericardial tamponade can only be speculative. The upper lobe was adherent to the adjacent pericardium and needed retraction of the mediastinum for its dissection; perhaps during dissection and securing bleeders an inadvertent needle stick through the pericardium caused the vessel injury and the blood collection in the pericardium would have increased once the retraction was released. The patient had hypotension during lung resection and postoperatively, which we attributed to surgical retraction and epidural blockade. Apparently, the intraoperative hypotension was because of surgical retraction and epidural blockade whereas the postoperative hypotension was because of epidural-induced venodilation and increasing blood collection in the pericardial cavity. Ronald et al,  reported pericardial tamponade in early postoperative period after a right upper lobectomy for lung cancer because of retraction of an aberrant vessel into the pericardial sac that bled subsequently. In our patient, the symptoms of cardiac tamponade occurred three days after LUL when the patient was ambulated. In acute injuries, a small amount of blood is enough to cause pericardial tamponade. In the presence of pericardial collection, the diastolic filling of the heart is limited and a greater venous pressure is required to fill the ventricles. Because of compromised diastolic filling of the heart, the ability of the heart to increase cardiac output is limited. Therefore, the patient complained of uneasiness on exertion (ambulation).The administration of midazolam worsened the hemodynamics by causing vasodilatation which further compromised diastolic filling of the heart.
Pericardial tamponade, though rare after open lobectomy, should be considered along with other complications when a patient repeatedly develops hypotension with therapies that causes venodilation. A rising CVP and its equalization with pulmonary artery diastolic pressure indicate cardiac tamponade. Transthoracic echocardiography can confirm the diagnosis. Treatment include an urgent pericardiocentesis as a temporizing measure followed by - a formal median sternotomy, which allows full inspection of the interior of the pericardium and provides adequate access for definite management of the cause.  We suspected rotation of left lower lobe as the cause of rapid clinical deterioration; therefore, the patient was explored through the left thoracotomy wound.
To summarize, in a patient, cardiac tamponade and circulatory collapse occurred after left thoracotomy for LUL excision. As demonstrated in this case, minor injuries during retraction and dissection can produce life-threatening conditions like pericardial tamponade. Episodes of unexplained hypotension suggest a cardiac etiology; a high index of suspicion and urgent surgical intervention can prevent adverse outcome.
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Praveen Kumar Neema
B-9, NFH, Sree Chitra Residential Quarters, Poonthi Road, Kumarapuram, Trivandrum - 695 011, Kerala
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]