FLUID AROUND THE HEART AND LOW BLOOD PRESSURE FOLLOWING ESOPHAGEAL SURGERY

I was roused from sleep at 2am by the tense voice of the intensive care physician who had called me to come in and perform a emergency heart echocardiogram on a postoperative patient. He was having a heart attack with low blood pressure that was not responding to his frantic attempts to raise it. Upon arrival with the echo machine to the dimly lit unit the patient was in the corner with clear plastic bags of medicated fluids supporting his blood pressure hanging on a metal pole next to his bed with multiple infusion pumps blinking like lights from a Christmas tree. The bedside echo showed moderate amount of fluid around the heart with normal heart function but some impaired filling from the external pressure from the collection of fluid around the heart . While performing the echo I sensed someone behind me and when I turned peering through the darkness, with the image from the echo monitor reflecting off his glasses, was the surgeon who had performed the operation . Could he have been cutting near the heart during the operation I asked. I "put surgical staples through the diaphragm to tack up the esophagus" he responded. Knowing the inferior wall of the heart rest on the other side of the diaphragm I instantly understood why the heart tracings and blood tests looked like a inferior wall heart attack. I immediately contacted Wellington our referral center for open heart surgery. My colleague in Wellinton advised us under echo guidance to put a needle in the fluid around the heart and drain it and they would transfer the patient in the morning. With my adrenaline surging I said rather forcefully the blood would just reaccumulate and the patient would not be around in the morning. Thankfully we prevailed in sending him to Wellington by life flight. In Wellington my colleague performed a coronary angiogram which should no damage to the arteries supplying blood to the heart and then tried to drain the blood around the heart with a needle only for it to reaccumulate. The patient subsequently had a cardiac arrest and was taken to the operating theater with my colleague sitting on the stretcher frantically draining blood from a tube in the pericardium. The cardiovascular surgeons opened the chest and found staples through the diaphragm into the heart causing bleeding from the cardiac viens.The bleeding was stopped with repair of the cardiac viens and the patient made a complete recovery. Lesson learned don't try to drain a traumatic pericardial effusion without a cardiovascular surgeon present.