Case 13: Accumulation of delays in pericardial drainage leads to fatal outcome Cardiothoracic surgery CASE SUMMARY A female patient in her early 60s arrived by ambulance to ED shortly after midnight (00:43). She presented with a three-day history of increasing lethargy and dizziness. She was an active marijuana user. Medical history included chronic myelogenous leukemia under remission with chemotherapy, prior stroke and schizophrenia. She was hypotensive in ED, with BP 70–90 mm Hg. A rapid CT scan reported a pericardial effusion. A bedside echocardiogram (echo) was not done until 04:00, which confirmed a large pericardial effusion with characteristics of tamponade. Ninety minutes passed before the cardiac surgery team attended, and a further hour before the anaesthetist arrived. One hour later, the patient arrived in theatre—approximately seven hours after presentation at hospital. The patient was thought to be too uncooperative for preliminary relief of tamponade by aspiration under local anaesthetic. General anaesthetic induction occurred after 30 minutes of preliminary prepping and draping whilst the patient was still awake. She had a cardiac arrest shortly after induction. A sub-xiphisternal window was performed whilst closed massage progressed. Despite evacuation of 800 ml of blood-stained fluid, there was no improvement in haemodynamics. A full sternotomy and open massage, plus high inotropic support, resulted in restoration of circulation. Over the subsequent days in ICU, haemodynamics continued to improve but the patient failed to wake up. An MRI, performed on postoperative day four, demonstrated severe hypoxic brain injury. A decision for palliation was made and the patient died the following day.
DISCUSSION The delays to pericardial drainage are a concern. More than seven hours passed from presentation to the evacuation of the effusion. A vital component of this appears to be an unexplained interval of more than three hours in ED, between the diagnosis of a pericardial effusion on CT scan and the echo confirmation of not only a large effusion, but also of tamponade physiology.
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