The Anaesthetic Challenge in Open Pericardial Drainage in Severe Hypothyroidism: A Strategical Approach

Dear Editor, Pericardial effusion is defined as a buildup of fluid within the pericardial cavity. Pericardial effusion is one of the clinical symptoms linked with hypothyroidism. We report a clinical problem, primarily due to the discrepancy between the effusion volume and the patient’s clinical symptoms of severe hypothyroidism. A 54-year-old female with a documented history of hypothyroidism presented with dyspnea and semiconsciousness. She had a history of decreased oral intake and being unable to open her eyes for 3 days. She had reduced her activity over the last 3 years and steadily progressed. Upon evaluation, thyroid-stimulating hormone (TSH) was discovered to be 60 μl U/ml. An echocardiogram revealed an extensive pericardial effusion. Her CPK levels were increased to 310 U/L. Serum cortisol and adrenocorticotropic hormone levels were normal. Cranial magnetic resonance imaging and abdominal ultrasound were both normal. Contrast-enhanced computed tomography of the chest revealed no signs of thymoma. The thyroid gland’s ultrasound indicated tiny lobes and isthmus, as well as normal blood flow on colour Doppler. Echocardiography revealed Grade I diastolic dysfunction with a normal left ventricular ejection fraction. In cases of acute hemorrhage caused by rapid fluid accumulation, cardiac tamponade develops despite tiny amounts of fluid. General anesthesia (GA) was difficult due to the increased risk of cardiac collapse during induction; thus, we intubated with a titrated etomidate and fentanyl. After that, atracurium was used to paralyze the patient and ventilate him. To summarize, our experience leads us to the conclusion that subxiphoid pericardial drainage under GA was still effective, and cautious induction, but with little morbidity. We believe it is the preferred technique for patients with pericardial tamponade [Figure 1]. The patient was given 150 μg of thyroxine three times each day. After 1 week of treatment, the patient’s condition improved considerably, including a significant increase in consciousness. Her muscle power also improved, albeit some residual weakness was still there.Figure 1: Intraoperative picture of the patient under general anaesthesia for open pericardial drainage.After receiving the same treatment for 2 weeks, the patient was released from the hospital and instructed to have regular monthly checkups. Until her free T4 and TSH levels returned to the normal range, her thyroid function tests were repeated every 2 months with the necessary dose titration. A noticeable increase in muscle power coincided with a progressive improvement in her sense of well-being. Following a month of monitoring, she no longer had any active complaints, and all of her hypothyroidism symptoms disappeared. The symptoms of pericardial effusions include dyspnea, tachycardia, tachypnea, hypotension, muffled heart sounds, paradoxical pulse, and raised jugular vein pressure; these can even result in cardiac tamponade.[1,2] A common symptom of cardiac tamponade is thoracic pain and pericardial friction, and many patients may also have concurrent pericarditis. Every patient in the recovery area must be closely monitored throughout the critical postoperative phase. In addition to standard invasive ventilation equipment, noninvasive ventilation equipment must be easily accessible during the surgical recovery period.[3] CONCLUSION A rapid management for severe hypothyroidism with pericardial effusion is an open pericardial drainage, which needs to be verified with rapid echocardiography alone. The safest anesthesia induction method was using etomidate. Postoperatively, oral thyroxine can be used to control thyroid function even in such severe conditions. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.