Pericardiectomy in post-traumatic suppurative constrictive pericarditis: case report

Abstract

A 13-year-old male was seen at the Hospital with a 5-months history of right chest swelling, pain and recurrent fever and breathlessness on mild exertion. There was a history of gunshot to his chest two and half years before presentation.On admission he was febrile with a temperature of 39°C. The chest wall swelling measuring 6 cm/6 cm was tender and fluctuant and needle aspiration yielded purulent fluids. His blood pressure and pulse were 110/60 mmHg (14.6/8 Kpa) and 100 per minute respectively. The chest radiograph showed massive cardiomegaly with pellets lodging in the right 5th costosternal joint. Echocardiography confirmed massive pericardial effusion. The electrocardiogram showed sinus rhythm and low voltage of QRS complexes without chamber enlargement. A diagnosis of constrictive pericarditis with purulent pericardial effusion secondary to foreign body abscess was made.His clinical picture improved after an initial incision and drainage of the right anterior chest wall abscess under ketamine intravenous anaesthesia. Two weeks after, he had pericardiectomy under general anaesthesia using a nitrous/oxygen/halothane relaxant technique which was uneventful.

Anaesthesia for Patients with Pericardial Disease

“…All patients require adequate peripheral access and standard ASA monitoring prior to any anaesthetic agent being administered [12,21,22,32,49,[51][52][53][54]. It may also be necessary to institute invasive monitoring via arterial and central venous lines when appropriate, ensuring that insertion of the lines does not delay definitive treatment.…”

“…Pericardiectomy is the only definitive treatment for established constriction, and most studies suggest that resection should be as complete as technically feasible [49,[54][55][56][57]. A retrospective review by Nozohoor et al showed that radical pericardiectomy was associated with improved functional status and 10-year survival rates of 94% compared to 55% with subtotal pericardiectomy [55].…”

“…Pericardiectomy is a very technically challenging operation with significant morbidity and mortality performed in high-risk patients [49,[54][55][56][57]59]. Intraoperative complications may contribute significantly to poor outcomes.…”

“…Intraoperative haemodynamic goals are to maintain heart rate, maintain systemic vascular resistance, optimise venous return and support myocardial contractility [12,21,22,32,49,[51][52][53][54]60]. General anaesthesia care including intraoperative acid-base management, correction of electrolyte abnormalities, temperature and glucose control is required and will apply to these patients as mentioned above for pericardial tamponade.…”

“…A balanced anaesthetic technique ensuring haemodynamic goals is necessary to avoid sudden decompensation at induction of anaesthesia [54,60]. Ketamine is often recommended as the anaesthetic induction agent of choice because of its sympathomimetic effects on the cardiovascular system.…”