Cardiovascular collapse with attempted pericardial drain wit
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Cardiac tamponade is a rare but serious emergency condition in the pediatric population. As a treatment, a pericardial drain is often placed to evacuate the fluid. Published in the Annals of Pediatric Cardiology, the authors present a case of a 4-year-old girl with cardiac tamponade secondary to renal failure.
After the tamponade resolved, she suffered cardiovascular collapse upon attempted drain withdrawal.

A 4-year-old girl with a complicated medical history of developmental delay, myelomeningocele, hydrocephalus, neurogenic bladder, and recurrent urinary tract infections had a 2-month hospital stay for urosepsis and hemolytic uremic syndrome. This led to chronic renal failure. She was discharged on peritoneal dialysis. She was stable at home for approximately 2 months when she presented to an outside emergency department for seizure-like activity and fever. She was found to be in distress, tachycardic, and tachypneic, with a distended abdomen, but maintaining normal oxygen saturations on room air.

She was given lorazepam, fosphenytoin, and antibiotics and transferred to the current facility. On arrival, a chest x-ray was performed that showed an enlarged cardiac silhouette suspicious for tamponade. For that reason, a transthoracic echocardiogram (TTE) was obtained. The TTE showed a moderate circumferential pericardial effusion with diastolic right atrial collapse suggestive of tamponade physiology. The patient was urgently taken to the catheterization laboratory. She remained hemodynamically stable during intravenous induction and endotracheal intubation.

A 6-French pigtail catheter was placed in the pericardial space under ultrasound and fluoroscopic guidance and secured in place with a self-adhesive securement device specifically designed for percutaneous drainage catheters; 220 ml of serosanguineous fluid was drained. The patient stabilized and after 2 days, the pericardial drainage was minimal and a decision was made to discontinue the drain. The cardiologist attempted removal at the patient's bedside.

The girl became unresponsive, had a decreased respiratory rate, and bradycardia. Chest compressions were initiated and the patient was ventilated via bag mask. Shortly thereafter, the patient started breathing spontaneously and had a palpable pulse. A bedside chest x-ray was performed in which the pigtail catheter appeared in the pericardial space but the exact orientation was unclear.

The patient was then transferred to the operating room (OR) for TTE-guided withdrawal of the drain. A TTE was performed under general anesthesia showing minimal effusion but the exact location could not be determined. With the code cart available and the team prepared, another attempt to blindly remove the catheter was performed in the OR. The patient became profoundly hypotensive and bradycardic. External cardiac compressions were initiated.

A 0.35 flex guidewire was passed into the catheter and the wire and catheter were advanced back into the chest several centimeters. The patient very quickly stabilized hemodynamically. The team felt the drain must be encircling a major vessel and decided to remove the catheter under direct visualization via sternotomy by a pediatric cardiothoracic surgeon. The catheter was found to course anteriorly and superiorly over the pulmonary artery and aorta and posteriorly and inferiorly under the heart.

The pigtail portion was adjacent to the atrial appendage. Traction on the catheter resulted in complete occlusion of main pulmonary artery and severe reduction in pulmonary blood flow. An abrupt fall in end-tidal carbon dioxide was also noted. The drain was surgically removed without further complication. The patient recovered from this episode in the pediatric intensive care unit.

Major takeaway:-
This case highlights an unusual cause for cardiovascular collapse, which occurred on blind removal of a pericardial drain.

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