(187) Immediate Postoperative Cardiac Tamponade Following Robotic Lung Resection Surgery: A Case Report

Introduction: Cardiac tamponade is a life-threatening emergency requiring immediate diagnosis and treatment to prevent antecedent mortality. Its occurrence after non-cardiac surgery is rare, and the diagnosis may often be missed. We discuss the development of cardiac tamponade in the immediate postoperative period after an uneventful robotic lung resection surgery and its prompt detection using bedside point-of-care ultrasound (POCUS).

Description: A 73-year-old male with hypertension, diabetes, and smoking history underwent an uneventful robotic assisted thoracoscopic right upper lobectomy and mediastinal lymph node dissection for lung adenocarcinoma under general anesthesia. He received 5000 units of subcutaneous heparin on induction of anesthesia, as per hospital protocol. The surgery was uneventful, with minimal blood loss and he tolerated one lung ventilation with stable hemodynamics throughout surgery. The surgical team performed an intercostal nerve block with liposomal bupivacaine under direct laparoscopic visualization at the end of surgery. His trachea was extubated uneventfully, and he was taken to the Post Anesthesia Care Unit (PACU) in a stable condition. Within 30 minutes, the systolic blood pressure dropped from 110 to 60 mm Hg and heart rate increased from the 90s to 120s. He was empirically treated with 20% intravenous fat emulsion and 2 L crystalloids for presumed local anesthetic systemic toxicity and hypovolemia. Due to his refractory hypotension, he was initiated on norepinephrine, vasopressin, and epinephrine infusions, and bedside POCUS revealed a 1 cm pericardial effusion with right atrial diastolic collapse, prompting emergent pericardial window creation. 100 mL of blood was surgically drained with immediate hemodynamic improvement. Postoperatively, he was admitted to the intensive care unit and was weaned off vasoactive support and extubated the next day.

Discussion: Pericardial tamponade is a life-threatening complication which can occur after video-assisted thoracoscopic surgery and should be rapidly ruled out in patients with refractory hypotension. POCUS is a useful diagnostic tool that can assist in diagnosis. Pericardial tamponade should remain on the differential for refractory hypotension after non-cardiac surgery.