Case study Anesthetic assessment

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Case study Anesthetic assessment Risk

• ??? Int ???

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Case Presentation

• A young man with a stab wound to the left
  anterior chest needs an anesthetic for an
  exploration of the wound. You are tasked to give
  the anesthetic.

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Case Presentation

• Significant clinical findings preoperatively are
• Semi-comatose
• BP 70/20
• Pulse rate 145/min
• Very soft heart sounds (hardly audible)
• ? ? JVP
• Pulses paradoxus (gt10mmHg decrease in systolic
  blood pressure with spontaneous inspiration)
• Cyanosis
• Anuric
• Hct .40

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Discussion

• Differential diagnosis
• Pathophysiological explanation
• Anesthetic management

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Differential diagnosis

• Cardiac tamponade
• hemothorax
• Tension pneumothorax
• pneumohemothorax
• Tracheobronchial injury

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Differential diagnosis

• Cardiac tamponade
• Becks triad hypotension, ? JVP, distant heart
  sound
• Chest discomfort
• Unconscious, obtunded, convulsion
• Tachypnea/dyspnea
• Renal failure / abdominal plethora / hepatic
  (shock liver) mesenteric ischemia
• Pulus Paradoxus
• Kussmauls sign

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Differential diagnosis

• Cardiac tamponade Dx
• EKG
• low voltage
• electrical alternans

• Echocardiography 

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Differential diagnosis

• Tension pneumothorax
• Cyanosis and shock
• Decreased breathing sound
• Hyper-resonant in percussion
• jugular vein engorgement
• Trachea deviation

• Hemothorax
• Cyanosis and shock
• Decreased breathing sound
• dullness in percussion
• jugular vein engorgement or collapse
• ? Hct

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Differential diagnosis

• Tracheobronchial injury
• dyspnea
• Pneumomediastinum
• subcutaneous emphysema
• Hemoptysis
• Still air leak from chest tube

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BP? HR?

• Cardiac tamponade is characterized by a continuum
  from an effusion causing detectable effects to
  full-blown circulatory collapse.
• an effusion reduces the volume of the cardiac
  chambers such that cardiac output begins to
  decline

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HR?

• The compensatory response to a significant
  pericardial effusion includes increased
  adrenergic stimulation and parasympathetic
  withdrawal, which cause tachycardia and increased
  contractility.
• CO ?gt brain blood supply ?gt Semi-comatose
• CO ? gt kidney blood supply ? gt Anuric
• CO ? gt peripheral blood supply ? gt Cyanosis

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Pulses paradoxus

• abnormally large decrease in systolic blood
  pressure (gt10 mmHg) on inspirations
• ??gt??????RA pressure ? gt systemic venous return
  ? gt RV volume ? gt the interventricular septum
  shifts to the left gt ?? stroke volume ? CO ?

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? ? JVP
Prominent systolic x descent and absence of
diastolic y descent (x descent atrial diastole,
y descent A?V )
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? ? JVP

• the right atrium is receiving blood from systemic
  venous. In pericardial tamponade, the right
  ventricle only fills during early systole, so
  that only an x descent is observed.

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Anesthetic management

• Volume expanding agents such as blood, plasma,
  dextran, or saline may be used, but only as
  temporizing measures
• the associated increase in intracardiac pressures
  and heart size may produce a further increase in
  intrapericardial pressure
• Increase peripheral resistance not effective
  (tamponade has evoked maximal endogenous
  sympathetic response)

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Anesthetic management

• Preoperative prepare
• It would be unwise to administer any type of
  anxiolytic. Sympathoadrenal activation exists to
  support perfusion to vital organ. By partially
  blocking this compensatory effect with an
  anxiolytic, cardiovascular collapse may ensue.
• Indwelling arterial access for beat-to-beat
  displaying of systematic arterial pressure and
  for obtaining blood gas
• Swan-Ganz catheter, debatable?

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Anesthetic management Choice of Intravenous
anesthetics drug

• Barbiturate
• Thiopental mild direct cardiac depression,
  lowers BP, compensatory tachycardia (baroreflex)
• non-barbiturate
• Etomidate little change in cardiac function,
  mild dose-related respiratory depression,
  decreased cerebral metabolism
• Ketamine Adrenergic activation (increase HR, BP,
  C.O. ), minimal respiratory effect
• Propofol GABA receptor, respiratory and
  cardiovascular depression

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Anesthetic management

• Intraoperative
• Positive pressure mechanical ventilation should
  be avoided in patients with acute tamponade
  because it further reduces cardiac filling
• Chest opening normalize the pressure between
  pericardium and the heart chamber ? drastic
  improvement in blood pressure and SV ?vasoactive
  and cardioacive agent can be quickly weaned

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Anesthetic management

• Postoperative the timing of extubation
• Clinical stability
• stable hemodynamics without need for inotropic or
  vasoactive support
• Intact neurologic function
• alertness and ability to comprehend and execute
  simple verbal command
• Adequate pulmonary function
• Acceptable ABG and adequate weaning parameters
• Normal BT and neuromuscular function

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Thanks for your attention!!

• Reference
• Yao Artusio's anesthesiology problem-oriented
  patient management, 5th ed