pericardial effusion

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Case Presentation : 

Case Presentation Dr.kailash raj FCPS-2 Trainee

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73 Year old male Zubaid abbasi was admitted thru A&E on 23nov2010 with Shortness of breath 08days High grade fever 08days Loose Motion &Vomiting 05days According to pts attendant he was in his usual state of health that 8days back he started developing SOB that was aggravated on walking & lying down and relieved by sitting and leaning forward. It was associated with high grade fever sudden in onset associted with sweating and rigors for that he took antipyretics at home, besides he also had vomiting and watery loose motions; not having blood, pus or mucus.No H/O Chest pain. He was admitted at ashfaq memorial hospital for 3 days for above mentioned complaints but got no relief and rushed here.

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PMHx: Lt Sided Pneumonia Dec 2009 Treated with Antibiotics and advised bronchoscopy but was not done PSHx: Not Significant Personal Hx: Dec: Appetite Regular Bowel Habits Normal Micturation Ex-smoker No History of Wt:loss

Drug History : 

Drug History Medications: Inj: Klaricid Tb. Fexet Tb zentro Tb colchine Syp. Pulmonale

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Family Hx: Not Significant Socio-economic Hx: Fair

General Physical Examination : 

General Physical Examination Old aged Male; anxious tachypenic; sitting leaned forward oriented to TPP. Examination: A-ve, J-ve, Clubbing-ve, Cyanosis-ve Dehydration+ve, Bilateral Pedal Edema, Lymph nodes not Plapable, JVP Raised HR = 116 – reg / RR = 28 / BP = 130/90 SpO2 = 96% with oxygen / T = 98.6F

Systemic Examination : 

Systemic Examination Chest Examination - “Good AE – R>L, B/L crepts; more on lt side” CVS Exam- S1+ S2 Muffled No added sounds No rub CNS Examination - Intact Abdominal Exam- Soft, Distended &NonTender - BS present

Differential Diagnosis : 

Pericarditis Pneumonia Gastroenteritis Pericardial effusion Cardiac temponade Sepsis Differential Diagnosis

Investigation : 

Investigation CBC = 13.4 / 29.2 / 182 Neut = 93% UCE= Na= 119 K+= 3.7 CL:96 Bicar=17 Urea= 176 Crt=1.8 LFTs = Bilirubin = 5.3 conjugated 2.5 AST= 680 ALT = 1665 ALP = 395 GGT = 175 Albumin = 3.0 PT= 54(13) APTT=30(30) RBS 168

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Pericardial fluid: Gram Stain: No organism seen Culture: NoGrowth AFB Smear: AFB Not Seen D/R: not possible due to pus Specimen AFB Culture: Awaited

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ECG: Rate:110/min sinus rhythm, low voltage QRS complexes, no ST-T wave changes Echo: Normal size LV with Preserved systolic function Normal valves Moderate sized pericardial effusion surrounding whole heart EF: 55%

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CXR: Cardio-megaly Lt Sided consolidation U/S: B/L Grade 1 renal parynchymal changes Lt Sided Pleural effusion

Pericardial Effusion : 

Pericardial Effusion

Pericardial Effusion : 

Pericardial Effusion Presence of abnormal amount of fluid in the pericardial space Normally 15-50 mls of fluid Function – minimise friction between visceral and parietal pericardial layers Arises from visceral pericardium Essentially an ultrafiltrate of plasma

Pericardial Effusion : 

Pericardial Effusion Clinical manifestations vary with rate of accumulation Rapid accumulation -> elevated intracardiac pressure with 80mls Slow accumulation -> elevated intracardiac pressure may not occur until 2 litres

Pericardial Effusion : 

Pericardial Effusion Race No consistent difference among races is reported in the literature. AIDS patients with pericardial effusion are more likely to be white. Sex No sexual predilection exists. Age Observed in all age groups Mean occurrence in fourth or fifth decades; earlier in patients with HIV.

Clinical Presentation : 

Clinical Presentation Patient with pericardial effusion may report the following symptoms: Cardiovascular Chest pain, Characteristically, pericardial pain may be relieved by sitting up and leaning forward and is intensified by lying supine. Light-headedness, syncope Palpitations Respiratory Cough Dyspnea Hoarseness Gastrointestinal Hiccoughs Neurologic Anxiety Confusion

Clinical Presentation : 

Clinical Presentation Cardiovascular Classic Beck triad of pericardial tamponade (hypotension, muffled heart sounds, jugular venous distension). Pulsus paradoxus: Exaggeration of physiologic respiratory variation in systemic blood pressure, defined as a decrease in systolic blood pressure of more than 10 mm Hg with inspiration, signaling falling cardiac output during inspiration. Pericardial friction rub: The most important physical sign of acute pericarditis may have up to 3 components per cardiac cycle and is high-pitched, scratching, and grating. It can sometimes be elicited only when firm pressure with the diaphragm of the stethoscope is applied to the chest wall at the left lower sternal border. The pericardial friction rub is heard most frequently during expiration with the patient upright and leaning forward. Tachycardia Hepatojugular reflux: This can be observed by applying pressure to the periumbilical region. A rise in the jugular venous pressure (JVP) of greater than 3 cm H2 O for more than 30 seconds suggests elevated central venous pressure. Transient elevation in JVP may be normal.

Clinical Presentation : 

Clinical Presentation Respiratory Tachypnea Decreased breath sounds (secondary to pleural effusions) Ewart sign - Dullness to percussion beneath the angle of left scapula from compression of the left lung by pericardial fluid Gastrointestinal - Hepatosplenomegaly Extremities Weakened peripheral pulses Edema Cyanosis

Pericardial Effusion : 

Pericardial Effusion Causes- Infectious – bacterial, viral, fungal, parasitic, TB, HIV related- Autoimmune & connective tissue disorders e.g. rheumatoid arthritis, SLE- Trauma- Neoplastic- Radiation- Hypothyroidism Drugs Uraemia

Effusion & Tamponade : 

Effusion & Tamponade

Pericardial Effusion : 

Pericardial Effusion InvestigationsCXR – Enlarged cardiac silhouette -- Pericardial fat stripe“CXR is unreliable in establishing or refuting diagnosis of pericardial effusion”

Pericardial Effusion : 

Pericardial Effusion

Pericardial Effusion : 

Pericardial Effusion Investigations- CT Chest – may detect as little as 50mls of fluid- General data suggests fewer false positives than echocardiography- Disadvantage – transport of pt to CT scanner especially if unstable

Pericardial Effusion : 

Pericardial Effusion Investigations- MRI – can detect as little as 30mls- Transport and time taken to scan are major issues- ECG – Classic findings – low voltages, electrical alterans - Studies suggest ECG poor diagnostic tool

Pericardial Effusion : 

Pericardial Effusion Echocardiography- Doppler echocardiography is recommended in all patients in whom pericardial effusion or cardiac tamponade are suspected Gold standard- Large effusions seen as echo free spaces between visceral and parietal pericardium- Large effusions -> diastolic collapse of RA and RV, signalling tamponade- Large effusions are classified as > 1cm on echocardiography- Increasingly used in combination with pericardiocentesis

Pericardial Effusion : 

Pericardial Effusion Management- Pericardiocentesis - used commonly with agitated saline to determine if needle is in ventricle - Connection of ECG lead to needle “Electrical activity” seen on monitor when comes into contact with myocardium

Pericardial Effusion : 

Pericardial Effusion

Pericardial Effusion : 

Pericardial Effusion Complications of pericardiocentesis include ventricular rupture, Dysrhythmias, Pneumothorax, Myocardial and/or coronary artery laceration, and infection. Recurrence rates within 90 days may be as high as 90% in patients with cancer

Management : 

Management Initially, medical care of pericardial effusion is focused on determination of the underlying etiology. Aspirin/nonsteroidal anti-inflammatory agents (NSAIDs) Most acute idiopathic or viral pericarditis occurrences are self-limited and respond to treatment with aspirin (650 mg q6h) or another NSAID. Indomethacin should be avoided in patients who may have coronary artery disease.

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The routine use of colchicine is supported by results from the COlchicine for acute PEricarditis (COPE) trial. In this trial, 120 patients with a first episode of acute pericarditis (idiopathic, acute, postpericardiotomy syndrome, and connective tissue disease) entered a randomized, open-label trial comparing aspirin treatment alone with aspirin plus colchicine (1-2 mg for the first day followed by 0.5-1 mg/d for 3 mo). Colchicine reduced symptoms at 72 hours (11.7% vs 36.7%; P =0.03) and reduced recurrence at 18 months (10.7% vs 36.7%; P =0.004; 5 needed treatment). Colchicine was discontinued in 5 patients because of diarrhea. No other adverse events were noted. Importantly, none of the 120 patients developed cardiac tamponade or progressed to pericardial constriction.16

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Steroids: Steroid administration early in the course of acute pericarditis appears to be associated with an increased incidence of relapse after tapering the steroids. Systemic steroids should be considered only in patients with recurrent pericarditis unresponsive to NSAIDs and colchicine or as needed for treatment of an underlying inflammatory disease. If steroids are to be used, an effective dose (1-1.5 mg/kg of prednisone) should be given, and it should be continued for at least 1 month before slow tapering.

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Hemodynamic support Hemodynamic monitoring with a balloon flotation pulmonary artery catheter is useful, especially in those with threatened or mild tamponade. Intravenous fluid resuscitation may be helpful in cases of hemodynamic compromise. In patients with tamponade who are critically ill, intravenous positive inotropes (dobutamine, dopamine) can be used but are of limited use and should not be allowed to substitute for or delay pericardiocentesis.

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Antibiotics In patients with purulent pericarditis, urgent pericardial drainage combined with intravenous antibacterial therapy (eg, vancomycin 1 g bid, ceftriaxone 1-2 g bid, and ciprofloxacin 400 mg/d) is mandatory. Irrigation with urokinase or streptokinase, using large catheters, may liquify the purulent exudate, but open surgical drainage is preferable. The initial treatment of tuberculous pericarditis should include isoniazid 300 mg/day, rifampin 600 mg/day, pyrazinamide 15-30 mg/kg/day, and ethambutol 15-25 mg/kg/day.

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Surgical Care Subxiphoid pericardial window with pericardiostomy. This procedure is associated with low morbidity, mortality, and recurrence rates, and can be considered as a reasonable alternative diagnostic or treatment modality to pericardiocentesis in selected patients. Thoracotomy This should be reserved for patients in whom conservative approaches have failed. It allows for creation of a pleuropericardial window, which provides greater visualization of pericardium. Video-assisted thoracic surgery Video-assisted thoracic surgery (VATS) enables resection of a wider area of pericardium than the subxiphoid approach without the morbidity of thoracotomy.

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Mortality/Morbidity The mortality and morbidity of pericardial effusion is dependent upon etiology and comorbid conditions. Idiopathic effusions are well tolerated in most patients. As many as 50% of patients with large, chronic effusions were asymptomatic during long-term follow-up. Pericardial effusion is the primary or contributory cause of death in 86% of cancer patients with symptomatic effusions. Survival rate for patients with HIV and symptomatic pericardial effusion is 36% at 6 months, 19% at 1 year

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