Describe the implications for the conduct of general anesthesia in this patient

Describe the implications for the conduct of general anesthesia in this patient.

With the surgeon present in the operating room, general anesthesia is induced only after the skin has been prepared and the surgical drapes placed. This is to ensure that if further hemodynamic compromise ensues upon induction of general anesthesia, rapid and immediate pericardiocentesis can be performed. The venodilatation and hypotension that occur upon induction of general anesthesia can cause devastating hypotension in the patient with cardiac tamponade. In addition, it is important to minimize the time from induction of anesthesia to relief of the tamponade. Strong consideration should be given to performing pericardiocentesis under local anesthesia, as this would maintain hemodynamic stability prior to drainage.

The hemodynamic goals to be achieved on induction of anesthesia are:

·          Adequate inotropic state

·          Increased heart rate

·          Increased filling pressures

·          Avoidance of vasodilatation

·          Avoidance of myocardial depression

Induction of general anesthesia is often achieved with the use of ketamine or etomidate. Ketamine can cause myocar-dial depression at high doses or in the patient who is in a chronic state of myocardial failure. Potent inotropic and vasoconstrictive medication should be available to treat hemodynamic decompensation. There is a risk of circula-tory collapse and/or pulmonary edema following relief of the tamponade.