Over the course of my training as a cardiac anesthesiologist and intensivist, I’ve come across many manifestations of cardiac compression ranging from hemorrhagic pericardial effusions to massive clots. Although the general teaching is to keep these patients “fast, full, and forward” by increasing the heart rate and intravascular volume status, it doesn’t change the need to consider effective preload, baseline pulmonary hypertension, and effects of positive pressure ventilation on right ventricular dynamics.
General endotracheal anesthesia (GETA) secures the airway, maintains appropriate oxygenation/ventilation, and provides a means to perform transesophageal echocardiography (TEE) to assess cardiac function after the intervention (pericardial window, clot evacuation, etc.) In some patients, placing a pericardial drain with only local anesthesia IS a possibility, but in the population I take care of (ie, fresh VADs in redo-redo- sternotomies with adhesions and “thick” chest walls), it’s not as straightforward as one might think.
This is one of the scenarios where I want my surgical colleagues not only nearby but scrubbed in with the chest prepped and instruments ready prior to induction of general anesthesia. I typically use agents like ketamine, fentanyl, and succinylcholine flushed in with epinephrine, norepinephrine, and calcium to keep things as stable as possible. As soon as the airway is secured, I tell the surgeons to immediately proceed with their operation and provide support in the form of pressors, inotropes, and fluids along the way.