P012: ACUTE TAMPONADE IN A PEDIATRIC PATIENT NECESSITATING EMERGENT PERICARDIOCENTESIS: A CASE STUDY
Stephanie N Schock, MD1, Gohalem Felema, MD2; 1Mayo Clinic Jacksonville, 2Nemours Children's Specialty Care
Acute cardiac tamponade occurs rarely in the pediatric population. It is a life-threatening emergency and yet there is little medical literature on management of children with large pericardial effusion causing tamponade. Most cases are caused secondary to cardiac surgery, central venous catheter placement, pericarditis, malignancy, trauma, or collagen tissue disease. Successful outcomes demand early recognition and appropriate intervention. The need for pericardiocentesis versus cardiac window depends on the underlying cause and severity of presentation. This case describes an obese otherwise healthy 15 year old female who was transferred from an outside facility. She complained of persistent headache for the past 10 days with some improvement with naproxen and ibuprofen. She presented to an outside clinic after developing shortness of breath and chest pain for 2 days and was sent home after a chest x-ray was taken. The patient was transferred to the emergency room for further workup when she developed palpitations, worsening fatigue and inability to lay flat. The chest xray was reviewed and showed cardiomegaly. An ECG demonstrated elevated t waves and tachycardia. D dimer was 1.26, CK 650, CK MB 3.61, troponin of 0.2 and lactate 2.4. Hbg 10 and WBC 17. Bedside echocardiogram was performed and showed normal cardiac anatomy and function with a large circumferential pericardial effusion with clear tamponade physiology. The patient was taken emergently to the operating room for a pericardialcentesis with catheter placement which drained 380 ml serous fluid. Anesthetic management of this patient was challenging due body habitus weighing 96 kg and acute presentation of the tamponade. By the time the patient made it to the operating room there was significant ST segment changes with electrical alternans. She had progressive narrow pulse pressure width with worsening tachycardia and reduced peripheral perfusion. Initial vitals were BP 107/80, HR 123, SpO2 100% on 10 L non-rebreather. An awake arterial line was performed under local anesthesia and ultrasound guidance. The patient was positioned sitting upright, pretreated with glycopyrrolate and sedated with boluses of ketamine and versed with low dose fentanyl keeping spontaneously breathing throughout case. Systolic BP remained in 120s with HR in the 130s throughout the case. Immediate improvement of narrowed pulse pressure was seen after drainage of the pericardial fluid. BP 140/72, HR 132 and SpO2 of 100%. The patient tolerated the procedure well and was taken to the CVICU on nasal cannula. Initial work up of diabetes, bacterial infection and rheumatologic disorder was negative. Patient was discharged on ibuprofen and zantac and scheduled to follow-up with cardiology.