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.
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