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Anesthesia for pericardial window in a pregnant patient with cardiac tamponade and mediastinal mass

[Anesthésie pour une fenêtre péricardique chez une femme enceinte qui présente une tamponnade cardiaque et une masse médiastinale]

¹ From the Department of Anesthesia, Kelowna General Hospital, Kelowna, British Columbia, Canada.

Address correspondence to: Dr. J. Anne Webster, Department of Anesthesia, Victoria General Hospital, One Hospital Way, Victoria, British Columbia V8Z 6R5, Canada. Phone: 250-727-4212; Fax: 250-721-9020; E-mail: jawebster{at}shaw.ca

Purpose: To present a case report of anesthesia for pericardial window surgery for acute cardiac tamponade in a patient with an anterior mediastinal mass in late pregnancy.

Clinical features: A 34-yr-old gravida 2, para 1 patient presented at 29 weeks gestation with dyspnea, orthopnea, chest pain, and cough. Investigations showed an anterior mediastinal mass due to Hodgkin’s disease. A course of vinblastine at 31 weeks gestation resulted in symptomatic improvement but at 34 weeks gestation she developed an acute cardiac tamponade for which pericardial window drainage was required. Additional help and equipment were assembled in case of cardiopulmonary deterioration. Intra-arterial pressure and continuous fetal monitoring were established and iv access was secured in both arms and the left foot. After awake fibreoptic intubation, spontaneous ventilation was maintained. Anesthesia consisted of local anesthetic infiltration of the anterior chest wall, supplemented with fentanyl, midazolam, and ketamine. The patient remained stable, was extubated fully awake, and then monitored in an intensive care area.

Conclusion: This patient presented with acute cardiac tamponade and an anterior mediastinal mass in late pregnancy, an unusual combination of challenges that requires a careful approach to anesthetic management.