Critical Care Medicine-Hematologic and Oncologic Disorders>>>>>Solid Tumors
Question 2#

A 63-year-old woman with a recent diagnosis of lung cancer is admitted to the ICU with hypotension, acute onset of chest pain, cough, and shortness of breath. Her vital signs are:

Chest X-ray is notable for a right lower lobe consolidation, as well as widened mediastinum. Chest computed tomography with contrast reveals a large pericardial effusion and transthoracic echocardiography shows a large pericardial effusion with diastolic collapse of the right ventricle.

Which of the following is next most appropriate therapeutic intervention at this time?

A. Noninvasive positive pressure ventilation
B. Emergent endotracheal intubation
C. Echocardiography guided pericardiocentesis
D. Emergent radiation therapy

Correct Answer is C

Comment:

Correct Answer: C

The patient presents with respiratory distress and hypotension secondary to pericardial effusion with tamponade physiology. Emergent echocardiography–guided pericardiocentesis will evacuate the pericardial effusion and relieve symptoms.

Pericardial effusions are common in patients with metastatic cancer. However, most cancer patients with pericardial effusions are asymptomatic. Symptoms develop in patients with large pericardial effusions or those with rapid fluid accumulation. Typical symptoms include cough, dyspnea, and chest pain. Physical examination findings are notable for hypotension, tachypnea, tachycardia, respiratory distress, jugular venous distension, and pulsus paradoxus. Chest X-ray may show widened mediastinum and EKG may show sinus tachycardia, low voltage, nonspecific ST/T changes, and electrical alternans. Echocardiography is the gold standard for diagnosing pericardial effusion. Tamponade physiology is characterized by diastolic collapse of the right ventricle, dilatation of inferior vena cava, and loss of respiratory variability in IVC diameter as well as pronounced ventricular interdependence with respiration. 

Positive pressure ventilation reduces venous return (cardiac preload) and can lead to hemodynamic collapse (choices A and B are incorrect). Although radiation therapy may reduce the risk of recurrence, it has no role in acute management of pericardial effusion with tamponade physiology.

References:

  1. Maisch B, Ristic A, Pankuweit S. Evaluation and management of pericardial effusion in patients with neoplastic disease. Prog Cardiovasc Dis. 2010;53:157-163.
  2. Thorvardur R, Hogan WJ, Madsen BE, et al. Emergencies in hematology and oncology. Mayo Clin Proc. 2017;92:609-641.