POS-834 SPONTANEOUS RESOLUTION OF LARGE PERICARDIAL EFFUSION AFTER CARDIOPULMONARY RESUSCITATION IN A CHRONIC KIDNEY DISEASE PATIENT ON MAINTENANCE HAEMODIALYSIS

ABSTRACT

Introduction: Here, we discuss a chronic kidney disease (CKD) patient with large pericardial effusion who arrested secondary to tamponade and had an unintentional pericardial decompression secondary to cardio pulmonary resuscitation (CPR) that subsequently saved his life. Methods: PRESENTATION 67 years old male, a case of CKD on maintenance hemodialysis (for last two years) but inadequately dialyzed over last two months after recent covid pneumonia was detected to have large pericardial effusion (red arrows) on echocardiography (Figure 1). He was planned for intensive heparin free dialysis in view of absence of frank clinical and echocardiographic findings of tamponade with close surveillance for pericardial effusion. 60 minutes into hemodialysis, patient developed dyspnea, hypotension, and cardiac arrest. Return of spontaneous circulation was achieved after three cycles of cardiopulmonary resuscitation. Echocardiography (echo) guided pericardiocentesis was planned based on clinical suspicion of tamponade. But, echocardiography revealed only mild pericardial effusion (Figure 1). Chest x ray showed new left pleural effusion. Pleurocentesis revealed hemorrhagic fluid. Subsequently done CT thorax showed multiple rib fractures. Patient was discharged on day eleven in stable condition with repeat chest X ray and echocardiography showing no further collection. Figure1 Panel A ( Pre CPR echo, Large pericardial effusion - red arrows), Panel B (Post CPR echo, minimal pericardial effusion) [Formula presented] Results: DISCUSSION Though cardiac tamponade is largely a clinical diagnosis, various other features like echocardiography aid in its diagnosis. Diagnosis of tamponade in CKD patient with pericardial effusion is difficult because of several reasons. All classical clinical features of tamponade like hypotension or elevated systemic pressures may not be manifested all the time in cases of tamponade. Our patient developed clinical signs of tamponade 60 minutes into dialysis session indicating that precipitation of tamponade was likely due to reduction in preload due to ultrafiltration (UF) during hemodialysis. Though, daily dialysis is the initial preferred treatment of choice for uremic pericardial effusions in CKD patients without clinical or echocardiographic signs of tamponade, there are case reports which support early pericardiocentesis as treatment of choice in all large pericardial effusions in CKD patients on maintenance hemodialysis (MHD). In our case of large pericardial effusion, due to absence of frank clinical/ echocardiographic evidence of tamponade, we were prompted to go for aggressive dialysis treatment plan, but had tamponade during dialysis. CPR can cause inadvertent injury to surrounding structures, ribs, abdominal organs and vascular injury. In our case, CPR associated injury lead to unintentional pericardial decompression probably due to rib injury or due to high force generated during CPR coupled with high pericardial pressures which overcame the tensile strength of pericardium resulting in pericardial decompression. Findings of fractured ribs on CT scan post resuscitation in our case supports that high force and pressure were generated during CPR. Conclusions: This case report supports early pericardiocentesis as treatment of choice for large pericardial effusion in CKD patients on MHD. Also, care should be taken while dialyzing these patient as rapid UF can precipitate tamponade. No conflict of interest