The European Society Of Cardiology Health And Social Care Essay
Pericardial effusion is caused by many underlying medical and surgical conditions. Among the causes of effusion as cited by the European Society of Cardiology are of the following in accordance to incidence; idiopathic, infectious, immune-inflammatory, neoplastic diseases, radiation induced, early post-cardiac surgery, device and procedure related, blunt and penetrating trauma1. These underlying conditions cause massive effusion that impairs the functional ability of the human heart. In most cases, patients presenting with cardiac tamponade needs immediate surgical intervention. Among the drainage procedures, Subxiphoid pericardiostomy is one of the most common, easy, and high risk procedure subjected to a human pericardium.
The risk for subxiphoid pericardiostomy carries equivalent morbidity and mortality. The vast majority of the studies published in literature suggest that the subxiphoid pericardiostomy is an expeditious, easy, and inexpensive procedure, which can be applied to a wide spectrum of pericardial effusions. The technique provides accurate diagnosis and effective, durable treatment with an operation-related mortality ranging between 0% and 5 % and a recurrence rate 0 to 9.1%2
This study will determine the etiology and outcome of patients with pericardial effusion who underwent subxiphoid pericardiostomy. Furthermore, the study will also enumerate the different demographic and clinical characteristic of patients undergoing this procedure.
2. What has been known about the topic?
Subxiphoid pericardiostomy for the treatment of pericardial effusion has been elaborated in many articles worldwide3. The cause of pericardial effusion and the type of drainage procedure is often related to underlying conditions. This procedure is both diagnostic and therapeutic in nature.
Myriad of causes has been identified for pericardial effusion. In one case series study showed that out of 348 participants, uremia is the most common cause of pericardial effusion compared to what was identified by the european society of cardiology2.
In another european study, pericardial effusions and/or tamponade are reviewed and compared based on 12 years of surgical experience. They have concluded that choosing a method for pericardial decompression, it’s the disease etiology and patient characteristics must be considered as well as the experience of the surgeon.
Echocardiography is identified as the gold standard for the diagnosis of pericardial effusion. Thus, when the diastolic echo-free space between the left ventricular posterior wall and pericardium was 10 mm it was classified as mild, 10–20 mm was classified as moderate, and 20 mm was classified as severe pericardial effusion3.
Diagnosis of cardiac tamponade is achieved by clinical and imaging criteria. The presence of classic traid tamponade—distended neck veins, hypotension and muffled heart sound with clear lungs all together or with echocardiographic findings was accepted as cardiac tamponade. Furthermore, there were no mention in literatures the use of conventional ultrasound for the diagnosis of pericardial effusion. However, In an asian study, conventional ultrasound was used in traumatic pericardial effusion and distance between the pericardium and the myocardium was the basis for indicating a free space for pericardisotomy
Echocardiographic criteria of tamponade were examined by two dimensional and Doppler echocardiography. Two dimensional echocardiographic criteria of tamponade were early diastolic collapse of the right ventricle, late diastolic collapse of the right or left atrium, and plethora of the inferior vena cava with pericardial effusion4. Doppler echocardiographic criteria of tamponade were major increases of tricuspid E flow and major decreases of mitral E flow during inspiration compared with apnoea (with the reverse in expiration).
There are many clinical presentation of pericardial effusion. Pericardial disease is a common entity, pericardial tamponade is the usual presenting feature. It occurs in about 25% of all cases of pericardial effusion. Symptomatic pericardial effusions occur as a result of multiple disease processes and can be treated with many different procedures. Pericardiocentesis, transcutaneous pericardioscopic, pleura-pericardial window, and subxiphoid pericardial drainage4. Each of these surgical treatments can be effective, depending on clinical factors and the history of the patient. For this reason, the optimal procedure for treatment of these effusions remains controversial, and none of them is optimal for all patients and circumstances.
Pericardiocentesis is life saving in cardiac tamponade and indicated in effusions4. The most serious complications of pericardiocentesis are laceration and perforation of the myocardium and the coronary vessels. Safety was improved with echocardiographic or fluoroscopic guidance.
The ideal procedure should be easy to perform, result in minimal morbidity and mortality, ensure complete and permanent drainage, have infrequent recurrences, and provide sufficient histological, cytological, and microbiologic specimens for diagnosis of the cause of the effusion.
The potential advantages of subxiphoid pericardiostomy are direct visualisation and exploration of the pericardium and pericardial cavity, the ability to probe the pericardial cavity to allow for complete drainage, biopsy of the pericardium for pathological analysis, and placement of a larger calibre tube for better drainage. Video assisted transthoracic pericardial drainage has been touted as effective for preventing effusion recurrence through a large pericardial resection with the creation of a ‘‘pericardial window’’. It requires, however, general anaesthesia and single lung ventilation, procedures that are difficult in critically ill patients. In a series of 368 patients with pericardial effusion, subxiphoid pericardiostomy was performed under local anaesthesia with sedation (n = 346, 94%) or general anaesthesia (n = 22, 6%) during the 13 years between 1990 and 2003. General anaesthesia was preferred for children. Pericardiocentesis was performed as a temporary procedure on 15 of our 368 patients4.
Different methods and approaches are described, which are summarized below:
Needle aspiration. This method has been used for decades the advantages and disadvantages have been well described in previous reports.
2. Small plastic tube drainage. This method has a disadvantage, the small tube becomes plugged up and the pericardial fluid is left behind because of loculations.
3. Anterior thoracotomy with or without video-assisted thoracic surgery. This method at times necessitates a chest tube.
4. Classic subxiphoid pericardial window. The safety of this method depends greatly on whether the pericardium contains fair amounts of fluid and/or is grossly adherent to the heart or occupied by metastatic tumor. Cases with bleeding into the pericardium due to imbalance of anticoagulants or to myocardial infarctions are problematic, and percutaneous tube pericardiostomy decompression should be considered only if the preoperative echocardiogram indicates significant pericardial effusion with fluid volume greater than 100 to 150 mL without loculation.
What is not yet known about the topic?
There has been no local statistical data yet in Mindanao regarding the clinical profiles of pericardial effusion who underwent subxiphoid pericardiostomy. This will determine the etiology of pericardial effusion who has undergone subxiphoid pericardiostomy.
What is the significance of the study
The study focused on the descriptive statistics. This is a pilot study for patient with pericardial effusion who underwent subxiphoid pericardiostomy in our locality. The demographic, clinical and etiology of pericardial effusion and the indications for pericardiostomy will be enumerated in this study.
What will your study do?
What are the profiles of patients with pericardial effusion who underwent subxiphoid tube pericardiostomy in Southern Philippines Medical Center from January 1, 2008 to December 31, 2012.
The study aims to describe the demographic and clinical characteristics of patient with pericardial effusion who underwent subxiphoid pericardiostomy.
1. Describe the patient with pericardial effusion who underwent subxiphoid pericardiostomy to demographic and clinical characteristic and correlate these as to:
D: Pre-operative imaging
E: Histologic findings
F. Pericardial fluid studies
G. patient’s immediate outcome
2. Determine the etiology of pericardial effusion undergoing subxiphoid pericardiostomy
Figure 1. Conceptual Framework
Southern Philippines Medical Center Patients
Pericardial effusion who underwent subxiphoid pericardiostomy
1. Pre-op imaging
2. Histologic finding
3. Pericardial fluid
4. patient’s outcome
The study employed a retrospective, descriptive study. A chart review will be employed in this study. The source will From January 1, 2008, to December 31, 2012. This review of charts is with the permission of the medical records department as approved by the SPMC Department of Surgery and Hospital Research Committee (HRC). Only admitted patients or in-patients were included in this study.
This study will include all patients who have undergone subxiphoid pericardiostomy for pericardial effusion at Southern Philippines Medical Center regardless of age, causes, co-morbidity, and post-operative status.
Patients who were admitted as a case of pericardial effusion but did not consent for pericardistomy will not be included in the study.
Definition of terms
Age- age in years of the individuals (mean)
Sex of the subjects- categorized as male or female
1. Pre-operative imaging – it include whether a subxiphoid conventional ultrasound
or 2d-echo cardiac ultrasound was done
2. Histologic findings – the findings might be
sub-categories to infectious (bacterial, viral, fungal), immune-inflammatory or normal tissue
primary or metastatic
Pericardial Fluid studies – defined as findings interpreted in
gram stain. Results may be gram positive stain or negative stain.
culture study – culture includes complete identification of microorganism
acid fast bacilli stain – results may be positive stain or negative stain
KOH stain – results may be KOH stain positive or negative stain
Cell cytology – results may be presence of malignant cells, benign or negative cytology results
4. Result/Disposition - defined as the status or condition of the patients after
Receiving medical and/or surgical interventions as defined
Result/Disposition is categorized as:
Discharged Against Medical Advise
Research Protocol Approval
The research protocol will be submitted to the hospital research committee together with the ethics committee for review and approval. Data collection and research analysis will be conducted upon the approval of the HRC and Ethics Committee.
Data encoding will be undertaken using the Microsoft Excel 2007. Variables with missing data were left blank. The data will be imported in the Epi Info version 3.5.1. Descriptive data such as the mean, percentage and standard deviation will be computed using the latter software program.
Area and Budgetary Requirements
The study will be conducted in SPMC, Bajada, Davao City. The charts will be collected from the medical records section of the hospital with the permission of the section head and as per approval of the HRC. Data collection and analysis will take place in two months.
Expenses incurred will be allotted to the production of data collection forms and reproduction of the initial and final drafts pending the approval of the hospital research committee. No funding agencies will be tap to pursue this investigation. Lastly, there are no conflicts of interest involved in this proposal.
Southern Philippines Medical Center
Institutional Review Board
The protocol of this research will be submitted for approval to the Southern Philippines Medical Center Institutional Review Board (SPMC-IRB). A request letter will be submitted to the Chief of Hospital and Records Section Head to access patient’s data.
I will not contact any participants through phone calls or home visit since all the data I will be needing is already in the data form.
I will collect the data devoid of personal information like name, addresses, phone numbers or e-mails. The data will be in both hard and soft copy. Hard copy will be kept in our department for future reference. I will keep the soft copy for about 5 years. Only I and the consultant in charge as well as the statistician can access the data for analysis.
EXTENT OF USE OF STUDY
There are no plans to use the data other than to answer the objectives stated in my protocol. There are no plans to make the data available to others.
AUTHORSHIP AND CONTRIBUTORSHIP
I will be the primary author and Dr. Josel Rey Aguelo will be my co-author. He will contribute to this paper all throughout. He will be acknowledged in the final write up of this paper and in any output of this research.
CONFLICTS OF INTEREST
I declare no conflict of interest.
This paper will be made with the intention of possible publication
The source of study funds will be the principal investigator.
You can call or text me thru my cell phone 09177012211 or e-mail me in this address:
DUMMY 1: AGE DISTRIBUTION
18 – 27
28 – 37
38 – 47
48 – 57
58 – 67
68 – 77
78 – 87
88 – 97
DUMMY 2: GENDER DISTRIBUTION
DUMMY 3: PRE-OPERATIVE IMAGING
DUMMY 4 HISTOPATHOLOGIC FINDINGS
DUMMY NO. 5 PERICARDIAL FLUID STUDIES
ACID FAST STAIN
DUMMY 6. ETIOLOGY
DEVICE AND PROCEDURE RELATED
BLUNT AND PENETRATING TRAUMA
DUMMY 7: SURGICAL OUTCOME
Discharged Against Medical Advise