pericardial drainage for cardiac tamponade. Non

Non-cardiogenic pulmonary edema after pericardial drainage for cardiac tamponade. F Glasser, A M Fein, S H Feinsilver, E Cotton and M S Niederman Chest 1988;94;869-870 DOI 10.1378/chest.94.4.869 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/94/4/869

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selectedreimrts NonCardiogenic Pulmonary Edema after Pericardial Drainage for Cardiac Tamponade*

,

,

Glasser

We

report

a

patient

syndrome

distress

ade. Because in this

situation, fluid

massive

developed

we with

fluid

recommend

shifts

ericardiocentesis

for

ponade

to a variety

may lead

perforation

of

arteries,

the

the

right

Recent

1

severe

pulmonary

one

patient,

nary

edema

cular

resulted with

persisted

capillary

sac. that

unit

was

respiratory

distress

knowledge ously.

this

cardiac

septal

with

procedure.2.3 that

the

In

No

he-

bloody

fluid.

blood

pressure

emergency

was room.

perAfter

Following

to the

the

increased operating

of unknown

edema,

which

silhouette

of the

mm

room

for a partial

pericardial

Hg and

the

effusion

the

patient

was

pericardiectomy.

An intra-

had

decreased

in

size

with

diffuse

bilateral

alveolar

infiltrates consistent with pulmonary edema. Initial arterial blood gas levels (F1o2= 1.0) were pH, 7.48; PaCo2, 36 mm Hg; Pa02, 62 mm Hg. He remained severely hypoxemic on a F1o2, 1.0 with bilateral infiltrates and normal microvasculature pressures for the next week (Table 1). The patient’s chest roentgenogram (Fig 2) gradually showed clearing and his hypoxemia slowly improved over two weeks at which time he was extubated. Cytologic and microbiologic studies of the pericardial fluid were unremarkable.

ml

obtained of the

in our alveolar

from

the

Our

patient

developed pericardial distress

developed following fluid, although the

of 2, 100

for

release

to 110/70

operatively placed Swan-Ganz catheter revealed pulmonary artery pressure of37/18 mm Hg and a pulmonary artery occlusion pressure of 12 mm Hg. Chest roentgenogram (Fig 1) revealed the cardiac

of a large respiratory

chest

roentgenogram

pulmonary

edema

during

effusion. The immediate suggests that the pulmonary withdrawal pulmonary were

drainage onset of edema

of 100 ml of pericardial artery catheterization and

performed

60

minutes

after

this

adult

in this

patient.

To our

been

reported

previ-

not

pericardiocentesis in the

of

DISCuSSION

patient.

responsible

has

volume

pulmo-

flooding.

drainage

seen

approach

microvas-

tamponade

part

complication

REPORT

with Down’s syndrome and a ventricular defect which had not previously limited his activity, presented dyspnea. Three months prior to admission he reported

symptoms

white

man

of an upper

respiratory

admission he developed with a 15 pound weight Physical with

this

Hemodynamic data increased permeability

CASE

A 33-year-old

and that

suggested

pulmonary

syndrome

coronary

have

alveolar

in

of

pneumothorax

for the second

following

at least

including

in pulmonary

severe

week

the pericardial patient indicated

elevation

with

tam-

pericardial

suggested

available

developed

for one

follow

subsequent

a patient

who

patients

data

data were

We describe

of

the dire

this

laceration

may

from

of peal-

to limit

of complications

of two

edema

pressure,

etiology

treatment

hemodynamic

modynamic

removal

hypotension,

reports

tamponade,

a subxiphoid

taken

tamponedema

to herald

ventricle,

arrhythmias,

respiratory

monitoring

which appear 1988; 94:869-70)

(Chest

complication.

gradual

hemodynamic

of suspected

formed

via

with an estimated

effusion

aspiration of 100 ml of fluid, the blood pressure fell to mm Hg and the patient developed markedly distended neck veins with respiratory distress and was intubated. An immediate left anterior thoracotomy was performed, draining 2,000 ml of

M.D.;

of pericardial ofpulmonary

recognition

pencardial

80/60

adult

relief

following

ofincreasing

cardial

P

who

in a large

1,500 ml. Because the

M.D.; Alan M. Fein, M.D. F,C.C.P; Steven H. Feinsilver, M.D. F.C.C.P; Elisabeth Cotton, and Michael S. Niederman, M.D. , F.C.C.!? Fred

swinging

examination

a pulsus

distant

with

remarkable

of

The neck a grade

3/6 systolic

for pitting

edema

blood

16

veins

infection;

dyspnea

revealed

paradoxus

24 per minute.

tract

progressive gain. mm

Hg

were

pressure and

legs.

week

100/60

Heart

murmur.

the

*Fmm Winthrop-

the

Department University

of Pulmonary Hospital,

and

sounds

and Health

of

were were showed

fields.

showed

Hg

rate

Extremities

with

echocardiogram

.

to

mm

Electrocardiogram

diffuse low voltage with electrical alterans. Chest revealed a markedly enlarged cardiac silhouette A two-dimensional

prior

associated

a respiratory

distended.

ejection ofthe

one

on exertion

roentgenogram

Critical Sciences

SUNY-Stony Brook, Mineola, New York. Reprint requests: Dr Fein, Department ofPulmonanj/Critical Winthrop-University Hospital, Mineola, NY 11501

clear heart

lung to be

Medicine, Center,

Care,

FIGURE

shows

1. Chest roentgenogram following partial pericardiectomy diffuse alveolar filling without pleural effusions. CHEST

I 94 I 4 I


OCTOBER, 1988

869

Table

1-Hemodynamic

and

Arterial

Blood

100/60 100/50

Pre-discharge

100/60

Pericardiectomy

procedure.

initial

Hemodynamic

a pressure

too

permeability

prolonged diffuse

low

were

illness

case

of the adult has

case,

been

reported

capillary

by

occlusion

of

twice

et

pressures

al,2

In

increased the

the

tamponade

thereby

allowed

overloading

a sudden

increase

the left ventricle

resistance remained animal data which

impaired

to a greater

pencardial

tamponade,

high.

This

indicate

that

extent

and

contrast,

our patient demonstrated capillary occlusion pressure

monary

refractory

hypoxemia,

following

requiring

that

of

return,

systemic

elevated,

different

such

40

.31

76

hemodynamic

profile

adult

pulmonary

respiratory

distress

strated

The during

at which Such

initial

possibility.

and

thus

rupture and been demon-

distension

lends

missed

noted

support

catheter

have

increase microvas-

pulmonary

venous

artery may

mm Hg rarely

hypotension

has

ofneurogenic

in jugular

pulmonary

is only

ie vessel

rupture

pericardiocentesis

The later

of 100/60

pulmonary

injury,”

re-

substantially

where

vessel

this

pressure

not

is the sudden high

“blast

model

In

of ARDS

edema

explanation

increase

the

was

pressure

to extremely

in an animal

marked

thus

dis-

pulmonary

transfusions.6

pericardiocentesis led

occurred.

aspiration,

pulmonary

possible

pressure,

gastric

blood

In addition,

return

leakage,

is associated

and

his baseline

Another

cular

heart

edema

for the development the lowest blood

Hg

remains occlusion

congenital

emergency

mm

edema capillary

pulmonary

risk factor However,

following

occ’

minutes

I

62

1.0

pulmonary

as sepsis,

80/50

from

in

and with

1.0

underlying

multiple

recovery.

in venous

in his pul-

-

his pulmonary

despite

and

was

is of In

-

permeability

patient’s was

permeability

factors

reported by

function

and had prolonged mechanical ventilation

of this

Usually,

upon

vascular

a “mismatch” tamponade.

the

At no time

corded

release

in venous

characterizes

patient, the only was hypotension.

drain-

His

with

etiology

with risk contusion

that

pressures

no elevation

The

ease. one

In

pericardial

left ventricular permitting reliefofthe

preload

afterload,

only

hypothesis is supported right ventricular function

than

thereby

while

which

pressure.

consistent

Pa02

syndrome. uncertain.

pulmonary

age suggested that high pulmonary microvascular were responsible. The authors hypothesized

more

pressure

available.

following

and clinical

a pericardial

before.

measurements Vandyke

a

syndrome.

drainage

only

hemodynamic

reported

distress

the

end-expiratory

thus

edema,

developed

hypoxemia

positive

was

Hg,

if capillary

patient satisfying

following

an

of 12 mm

by refractory thereby

-

-

flooding

The

respiratory

edema

were

alveolar

infiltrates,

Pulmonary effusion

cause

37/18

15

pressure

increased.

characterized

alveolar

definition

to not

F1o2

-

12

demonstrated

occlusion

Artery

Pressure (mm Hg)

-

measurements

capillary

pulmonary

Pulmonary

Pressure (mm Hg)

100/60

Day7

Post. erzcardiocentesis

Occlusion

Pressure (mm Hg)

Before Pericardiocentesis Immediately Post-Partial

Pre- and

Pulmonary Capillary

Systemic

Time of Measurement

Gas Data

Blood

to

the

this

placed

was initial

60

pressure

changes. REFERENCES

1 Wong

B,

J,

Murphy

Chang

CH,

Am

J Cardiol

of pericardiocentesis.

2 Vandyke

WH Jr, Cure

J,

Chakko

edema after pericardiocentesis Med 1983; 309:595-96 3 Shenoy

MM,

edema

CS,

Gheorghiade

for cardiac

M, Gittin

Dhar

following

Hasseneon, Dunn 1979; 44:1110-14

for

M.

Sabado

cardiac

risk

Pulmonary

tamponade.

R, SinhaAK,

pericardiotomy

M. The

J

N EngI

M. Pulmonary

tamponade.

Chest

1984; 86:647-48 4 McHugh nary

TJ, Forrester

vascular

dynamic

JS, Adler

congestion

and

in

radiologic

L, Zion D, Swan HJC. myocardial infarction:

acute

correlations.

Ann

Intern

Pulmohemo-

Med

1972;

76:

29-33 5 Ditchey acute

R, Engler cardiac

R, LeWinter

tamponade

6 Fein A. Wiener-Kronish

I FIGURE

2. Chest

alveolar

filling

870

roentgenogram

pattern.

shows

clearing

of the

previous

physiology

Clinics 7 Chen resulting

of the

cerebral

Circ

Res

J1 Niederman

adult

respiratory

1986; 2:429-53 HI, Sun SC, Chal from

M. The role ofthe

in dogs.

1981;

M, Matthay distress

CY. Pulmonary compression.

heart

right

in

48:701-10

syndrome.

MA. Crit

PathoCare

edema and hemorrhage J Physiol 1973; 224:

Am

223-29

Non-cardiogenic

Pulmonary


Edema

(Glasser

at a!)

Non-cardiogenic pulmonary edema after pericardial drainage for cardiac tamponade. F Glasser, A M Fein, S H Feinsilver, E Cotton and M S Niederman Chest 1988;94; 869-870 DOI 10.1378/chest.94.4.869 This information is current as of July 10, 2011 Updated Information & Services Updated Information and services can be found at: http://chestjournal.chestpubs.org/content/94/4/869 Cited Bys This article has been cited by 2 HighWire-hosted articles: http://chestjournal.chestpubs.org/content/94/4/869#related-urls Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.chestpubs.org/site/misc/reprints.xhtml Reprints Information about ordering reprints can be found online: http://www.chestpubs.org/site/misc/reprints.xhtml Citation Alerts Receive free e-mail alerts when new articles cite this article. To sign up, select the "Services" link to the right of the online article. Images in PowerPoint format Figures that appear in CHEST articles can be downloaded for teaching purposes in PowerPoint slide format. See any online figure for directions.
