Standard monitoring, secure intravenous access, functional equipment, and skilled assistance should be prepared. Intravenous fluids, vasopressors, positive inotropes, and blood products should be immediately available. Preinduction invasive arterial pressure monitoring is required due to expected hemodynamic instability during the procedure. Although PAC data can be useful for intra- and postoperative optimization, a PAC is not essential for safe induction. TEE is a useful adjunct and should be utilized postinduction if a skilled operator is available. A rapid sequence induction with etomidate or ketamine as the induction agent; a rapid-acting neuromuscular blocking agent; and additional modifiers, such as midazolam, lidocaine, and an opioid, to ensure amnesia and to blunt the hemodynamic responses to tracheal intubation, should be the primary induction plan. During the preoxygenation process, the patient should be positioned in a way that considers the patient's comfort (eg, sitting upright) while allowing for quick conversion to a more favorable intubating stance following induction of anesthesia. Because of the potential for hemodynamic collapse with general anesthesia and positive pressure ventilation, it is imperative that induction only takes place once the patient is surgically draped and the surgeons are gowned and gloved ready for immediate chest decompression.

References

• Carmona P, Mateo E, Casanovas I, et al. Management of cardiac tamponade after cardiac surgery. J Cardiothorac Vasc Anesth. 2012;26:302-311.
• Morozowich ST, et al. Uncommon Cardiac Diseases. In: Kaplan JA, et al., eds. Kaplan's Cardiac Anesthesia. 8th ed. Elsevier; 2023:698-759.
• O'Connor CJ, Tuman KJ. The intraoperative management of patients with pericardial tamponade. Anesthesiol Clin. 2010;28:87-96.