Post-Cardiac Surgery Tamponade (EACTS/STS 2024)

Algorithm Steps

1. ▶

   Start

   Suspected Post-Cardiac Surgery Tamponade

   Hemodynamic instability in post-cardiac surgery patient

   1. ●

      Action

      Recognize Warning Signs

      Tamponade may present atypically post-sternotomy

      • ACUTE (first 24-48h):
      • • Sudden hypotension
      • • Elevated/equalizing filling pressures
      • • Sudden decrease/cessation of chest tube output
      • • Tachycardia, low cardiac output
      • DELAYED (>48h):
      • • Insidious hypotension
      • • Unexplained fever
      • • Pleural effusions
      1. ◆

         Decision

         Acute or Delayed Presentation?

         First 48 hours vs later

         1. ⚠

            Warning

            ⚠️ ACUTE TAMPONADE

            Often clot-related, may not be evident on echo

            • Classic signs may be ABSENT
            • Right-sided (RA/RV) compression most common
            • Clot may be loculated
            • Echo can miss posterior clot
            1. ◆

               Decision

               Hemodynamic Collapse / Arrest?

               Immediate vs urgent intervention

               1. ●

                  Action

                  IMMEDIATE BEDSIDE RESTERNOTOMY

                  Cardiac arrest or peri-arrest

                  • Do NOT delay for OR transfer
                  • Emergency sternotomy kit at bedside
                  • 5 essential items: scalpel, wire cutter, needle holder, sternal retractor, sucker
                  • Performed by surgeon or trained senior ICU staff
                  • No need for full sterile prep - use iodine-impregnated drapes
                  • Internal cardiac massage once chest open
                  1. ●

                     Action

                     Surgical Exploration

                     Evacuate clot, control bleeding

                     • Evacuate all clot and effusion
                     • Inspect for surgical bleeding source
                     • Repair if identified
                     • Generous irrigation
                     • Consider leaving chest open (delayed closure)
                     1. ✓

                        Outcome

                        Hemodynamics Restored

                        Continue ICU monitoring

               2. ●

                  Action

                  Urgent OR Resternotomy

                  If hemodynamically tenuous but not arresting

                  • Call cardiac surgery STAT
                  • Mobilize OR team
                  • Volume resuscitation en route
                  • Avoid excessive fluid (may worsen tamponade)
                  • Consider inotropes for bridge
                  1. ●

                     Action

                     Bridge Measures While Preparing

                     If any delay to OR

                     • Fluid bolus (cautious - 250-500 mL)
                     • Norepinephrine/epinephrine infusion
                     • Avoid bradycardia (tachycardia compensatory)
                     • Elevate legs
                     • DO NOT attempt pericardiocentesis (clot, not fluid)
         2. ●

            Action

            Delayed Tamponade

            May have time for imaging

            • Often fluid rather than clot
            • Echo more reliable
            • May develop over days
            • Consider anticoagulation-related
      2. ⚠

         Warning

         ⚠️ NO Pericardiocentesis

         Post-surgical tamponade is usually CLOT, not fluid. Pericardiocentesis will fail and delay definitive treatment.