"They're doing a pericardiocentesis in bed 11!" she informed me as she passed.
I went to bed 11 and took in the situation. An attending cardiologist and a cardiology fellow were at the bedside dressed in sterile gowns and gloves. The patient lay supine on the bed, a sterile blue drape over her chest. A table next to the bed held a pericardiocentesis kit, opened and ready.
My first action upon arriving was to assess the patient. She was awake, breathing oxygen via a non-rebreather facemask, and able to respond to questions. She was tachycardic to the 120s; her heart monitor showed electrical alternans; and her blood pressure, measured by a femoral arterial line, showed marked pulsus paradoxus with MAPs in the range of 35-55. In short, she had cardiac tamponade (a life-threatening condition) and looked pretty bad.
An ultrasound machine was at the patient's bedside and a technician was attempting without success to obtain a view of the heart and pericardium. "Stop with the ultrasound, I'm going to have to do this blind," the cardiologist told the tech.
As I watched, the cardiologist introduced the pericardiocentesis needle substernally, aspirating via a 60 ml syringe as he advanced. He directed the needle up and leftward, and his efforts were promptly rewarded with a gush of blood into the syringe as he entered the pericardium. The cardiologist breathed a sigh of relief and continued drawing back on the syringe, filling it to capacity before laying it aside and reaching for another.
The patient responded quickly to the decompression of her pericardium. Her blood pressure and tachycardia improved before our eyes and she stated that her dizziness had improved. Color returned to her face and she breathed more easily.
After removing about 150 ml of blood from the patient's pericardial sac, the cardiologist used an over-wire technique to place a pigtail catheter. He experienced some difficulty passing the catheter, however, and it was several minutes before the pigtail was in place. During this time, the patient's hemodynamic status quickly deteriorated once again. Finally, the cardiologist got the pigtail in place and began drawing blood from it. Once again, the patient's status improved immediately after the blood compressing her heart was removed.
As the cardiologist drew syringe after syringe of the patient's blood, I became concerned about the sheer volume of blood being removed. "I'm going to start giving this blood back to her," I told the cardiologist.
"Can you do that?" he asked.
"I don't see why not," I replied.
I grabbed the syringes full of blood (nearly 500 ml by this point, or about 10% of the blood volume of a grown person) and began pushing them back into the patient's bloodstream through her peripheral IV. At the same time, the cardiologist hooked a 3-way stopcock to the pigtail so he could suck blood out with a syringe and then push it into a collection bag. This new setup presented a problem for me since the collection bag was essentially a dead end -- it wasn't a bag that could be easily hooked to IV tubing, nor did it have a loop from which it could be hung. And blood was still coming from the pigtail.
Fortunately, a solution soon presented itself. When the cardiologist had struggled to place the pigtail catheter, he had damaged it and had ordered a new pericardiocentesis kit to be opened. When the collection bag hooked to the pigtail catheter held about 500 ml of blood, I switched it with the bag from the second kit. I spiked the first bag on regular IV tubing and quickly ascertained that the bag's port was slightly too large for the spike -- not large enough to leak, but large enough for the spike to slip out.
I joke with junior residents that most problems in anesthesia can be solved by a calm demeanor, tape, and the proper application of elbow grease. This proved to be one of those times. The preop nurse grabbed some 1" silk tape and we firmly anchored the IV tubing to the blood collection bag. Then we used the tape to create a loop on the bag, hung it up, and started dripping the patient's blood back through her IV.
While we treated the patient, the cardiologist and I had been discussing what to do next. He informed me that this woman had been undergoing coronary angiography and balloon angioplasty when the guidewire pierced her left anterior descending (LAD) coronary artery. Per standard procedure, she had been placed on an anti-platelet medication prior to her procedure; unfortunately, that medication was now preventing her blood from clotting to repair the hole in her LAD. The cardiologist wanted to go back to the cardiac catheterization suite to perform angiography, find the leak, and tamponade it with a balloon to seal the hole.
With this decision made, I went to my usual place at the head of the bed. I told the patient what we planned, reassured her that we would take good care of her, and asked her to keep me informed if she started to feel lightheaded again. And away we went.
By the time we arrived in the cath lab, the patient had begun feeling dizzy again. I grabbed a pair of 60 ml syringes and began withdrawing blood from the pigtail catheter, again with immediate improvement of the patient's symptoms. A nurse came over and together we formed an assembly line, I removing blood from the patient's pericardium and he giving it back through her IV.
Angiography was fruitless. The cardiologist was unable to see extravasation of his dye and so was unable to find the arterial defect that needed correction. As he examined the images, one of the hospital's cardiothoracic surgeons entered the cath lab. He and the cardiologist conferred and concluded that the patient would require surgery to correct her LAD defect. I called my attending and asked him to have someone prep the OR for us; he told me that someone was already setting it up.
And away we went again, this time to the OR. I talked with the patient as we went, explaining to her what her anesthesia would entail. She was understandably a bit shaken, and I reassured her once again that we would give her the best care possible.
We got her to the OR and onto the table. The CT surgeon, justifiably concerned that her continuing hemorrhage and cardiac tamponade would make her crash after induction of general anesthesia, asked us to place her lines with her awake, then prep and drape, and induce only when he and his team were scrubbed and ready for incision. My attending and I agreed and proceeded to get her lines set up. Two nurses continued pulling blood from her pericardium and autotransfusing it back to her while we worked. Since I'd started doing that, she'd had her entire blood volume removed through the pigtail catheter and given back through her IV.
The surgeon and his team scrubbed in once the patient was prepped and draped, and then they gave me the go-ahead to induce general anesthesia. My attending and I gave the patient just enough medication to put her to sleep, then I ducked under the drape to intubate.
The rest of the case went as smoothly as a cardiac case ever goes. The CT surgeon found the LAD defect and repaired it; he also found a puncture in the internal mammary artery that required surgical repair. The patient pulled through and was safely tucked into an ICU bed by dinnertime.
As I left the hospital that evening, I reflected on what I had done. The cardiologist had identified his patient's life-threatening cardiac tamponade and relieved it, but her rate of blood loss would have caused exsanguination had I not become concerned and started autotransfusing her own blood back to her. What I had done was a very simple thing, but it turned out to be a vital component of the patient's management and resuscitation. It even earned me a solid round of attaboys from the cardiologist, the CT surgeon, and my attending.
It's like I always tell the junior residents: a calm demeanor, tape, and the proper application of elbow grease.
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