Cardiac tamponade

Cardiac tamponade is usually manifest within 24 h of surgery but can develop 10 to 14 days after surgery in association with the postpericardiotomy syndrome or anticoagulant-induced rebleeding. It results in reduced cardiac output with compensatory vasoconstriction and tachycardia, and may lead to myocardial ischemia owing to the combination of reduced coronary perfusion pressure and reduced diastolic time. Classical signs include dyspnea, tachycardia, hypotension, distant heart sounds, pulsus paradoxus, and Kussmaul's sign. The ECG may show electrical alternans.

These signs are not reliable in the postoperative patient, because the pericardium is usually left open and most patients are ventilated, and the diagnosis depends on a high degree of suspicion. It should be considered whenever there is hypotension, tachycardia, and raised filling pressures, particularly if profuse chest drainage markedly reduces or stops suddenly. A chest radiograph typically shows mediastinal widening and, if time permits, echocardiography will confirm the diagnosis.

Treatment is by surgical re-exploration with evacuation of the hematoma. The chest may have to be reopened in the ICU if tamponade is sudden and severe, leading to hemodynamic collapse.

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