Pericardial tamponade caused by massive fluid resuscitation in a patient with pericardial effusion and end-stage renal disease -A case report-
A 73-year old male patient of 173 cm height and 52 kg weight visited hospital. The chief complaint was cellulitis in right ankle. He was under medication after being diagnosed with diabetes, hypertension, congestive heart failure, and left chronic tuberculous empyema ten years ago. He was undergoing hemodialysis three times a week after diagnosis of end-stage renal disease eight years previously. There were no specific findings during the hospital stay. He maintained normal blood pressure of 130/80 mmHg and heart rate of 65-80 beats per minute. Atrial fibrillation, normal left ventricular function, moderate concentric left ventricular hypertrophy, moderate pulmonary hypertension, severe tricuspid regurgitation, moderate mitral regurgitation, aortic regurgitation, and moderate pericardial effusion were observed in echocardiography () performed during his hospital stay. Left lung empyema, right pleural effusion, pericardial effusion were confirmed by chest CT scans () and simple chest X-rays () and pulmonary function test showed a moderate restrictive pattern. Hemodialysis was performed the day before the operation and the result of the complete blood count before hemodialysis were hemoglobin level 8.8 g/dl.\nOn the fourth day of his in-hospital stay, sudden respiratory distress occurred after performing needle aspiration test of the right pleural effusion. Despite taking a simple chest X-ray immediately, our medical staff could not find any cause and observed him with oxygen therapy via nasal cannula. Respiratory distress got worse at a respiratory rate of 30 times per minute and an oxygen saturation level of 85% with changing mental status. Our staff inserted right chest tube 2 hours 30 minutes after performing needle aspiration biopsy. Approximately 1,500 ml of blood was drained for about 10 minutes after chest tube insertion, with blood pressure of 90/40 mmHg, heart rate of 66 beats per minute, respiratory rate of 22 times per minute, and body temperature of 36.4℃. Rapid fluid replacement with 1L of normal saline via central venous catheter placed in the right internal jugular vein was performed and an emergency operation was decided upon. The patient's electronic medical record (EMR) was unidentifiable by anesthesiologists because of computer network error at that time. Hence, the emergency operation was began only by acknowledging that the patient with diabetes and hypertension was receiving hemodialysis and massive bleeding occurred during needle aspiration test at right pleura.\nHe was transferred to the operating room without any preoperative medication 20 minutes after chest tube insertion. At that time, his vital signs were blood pressure of 130/50 mmHg, heart rate of 60 beats per minute, respiratory rate of 22 times per minute, and body temperature of 34.9℃. He was stuperous and his skin was cold but other physical examination could not be performed. Preoxygenation was attempted with 100% oxygen at 8 L/min via mask and warm Voluven® (6% hydroxyethyl starch, Fresenius Kabi, Germany) was rapidly administered. In addition, non-invasive blood pressure, oxygen saturation, and electrocardiogram (ECG) were monitored. An arterial catheter for continuous hemodynamic monitoring was placed via the right femoral artery and a central venous catheter via the right femoral vein and 500 ml of Voluven® was rapidly administered. After IV administration of 90 mg ketamine and 50 mg rocuronium for induction, endotracheal intubation was performed with a 35 Fr left-sided double lumen endotracheal tube (Broncho-Cath®, Mallinckrodt Medical Athlone, Ireland) and flexible fiberoptic bronchoscope (LF-GP, Olympus, Japan) was used for confirmation of proper placement. During lung ventilation, tidal volume of 100-120 ml, a peak inspiratory pressure of 40 cmH2O, blood pressure of 130/50 mmHg, a heart rate of 65 beats per minute, and a central venous pressure of 17-18 mmHg in supine position was checked. We attempted to maintain anesthesia with 1.5 L/min of oxygen, 1.5 L/min of nitrous oxide, and 2 vol% of sevoflurane. However, inspired oxygen concentration was changed to 100%, sevoflurane administration was stopped, and 1 mg of midazolam was administered intravenously every 15 minutes after oxygen saturation fell to 84%. After the patient was changed to left-sided lateral position, the location of tube was confirmed by a flexible fiberoptic bronchoscope with a central venous pressure of 21 mmHg. Left one-lung ventilation (OLV) was performed five minutes after changing the position to left-sided lateral position. Tidal volume and oxygen saturation decreased to 170-180 ml and 80% respectively. Peak inspiratory pressure increased up to 38 cmH2O.\nImmediately on opening the right pleural cavity via right posterolateral thoracotomy, blood pressure decreased catastrophically and 1,500 ml of blood gushed out of the pleural cavity followed by about additional 1,200 ml of blood loss. Arterial blood gas analysis was performed 25 minutes after the beginning of surgery (). Subsequently, 3 L of Voluven® and 1 L of normal saline were administered rapidly during the half an hour after the beginning of surgery. At half an hour after the beginning of surgery, our hospital computer network was restored; packed red blood cells and fresh frozen plasma were administered. Then central venous pressure increased up to 38 mmHg with decreased active bleeding, fluid administration was minimized for concern about volume overload. Oxygen saturation level decreased continuously even though peak inspiratory pressure was above 40 cmH2O during one-lung ventilation. One-lung and two-lung ventilation were performed in turn along with manual and mechanical ventilation by maintaining tidal volume of 120 ml, respiratory rate of 60-70 times per minute, peak inspiratory pressure of 22 cmH2O, inhaled oxygen concentration of 100%, and oxygen saturation of 91-93%. Although fluid administration was minimized, central venous pressure increased up to 50 mmHg, blood pressure and heart rate were maintained at 120/60 mmHg and 67 beats per minute respectively and there were no abnormal ECG finding. Initial blood loss via chest tube before surgery was 1,500 ml, estimated blood loss during operation was 2,700 ml for 40 minutes and there was no urine output. The patient was administered 4,000 ml of Voluven®, 2,000 ml of normal saline, 5 pints of packed RBCs, and 5 pints of fresh frozen plasma. At 45 minutes after the beginning of surgery, central venous pressure suddenly increased up to 58 mmHg with falling in blood pressure of 70/40 mmHg, bradycardia of 25-30 beats per minute. 0.5 mg of atropine and 0.5 mg of epinephrine were administered immediately through a central line and the pericardium was checked by the surgeon for suspected pericardial tamponade while resuscitation was being prepared. The surgeon confirmed pericardial expansion and made a pericardial window immediately. After approximately 800 ml of yellow serous fluid with no blood was drained from the pericardial space, vital signs stabilized with recovering heart rate 60 beats per minute. Thereafter, blood pressure of 115/50 mmHg and heart rate of 65 beats per minute were maintained and central venous pressure was reduced to 45 mmHg. To maintain blood pressure, 20 mg of ephedrine and 1 g of calcium gluconate were administered divided. Arterial blood gas analysis was performed 30 minutes after pericardial window (). Although no active bleeding focus was found in the surgical field, blood leak continued under the damaged diaphragm. It was decided to observe the patient in the intensive care unit after primary closure. Flexible fiberoptic bronchoscopy was performed postoperatively and a small fresh blood clot was detected at the right bronchus. The patient was transferred to the ICU while maintaining a double lumen endotracheal tube from concern about failure of finding the bleeding focus and the risk of rebleeding. The total amount of fluid administrated during surgery was 4,100 ml of Voluven®, 3,000 ml of normal saline, 7 pints of packed RBCs, and 5 pints of fresh frozen plasma. Blood loss before surgery was 1,500 ml and intraoperative blood loss was 2,700 ml. Upon arrival on the ICU, the patient was stable with blood pressure of 97/72 mmHg, heart rate of 74 beats per minute and a tympanic membrane temperature of 35.7℃. No pulmonary edema was observed on postoperative chest X-ray (). Hemoperitoneum was confirmed on abdominal CT scan but we decided to observe carefully because there was no active bleeding focus in the abdominal cavity on the celiac artery angiogram. The patient exhibited stable vital signs after continuous renal replacement therapy during follow-up period and about 900 ml of bleeding via chest tube occurred on the first postoperative day. However, the chest tube was removed and hemoperitoneum was resolved as bleeding diminished 10 days postoperatively. Moderate pericardial effusion was detected again on echocardiography. The patient is currently admitted to the intensive care unit under mechanical ventilation due to respiratory failure.