Hemorrhagic cardiac tamponade in critically ill patients with acute renal failure Epaminondas Zakynthinos, MD, Maria Theodorakopoulou, MD, Zoi Daniil, MD, Kosmas Konstantinidis, MD, and Spyros Zakynthinos, MD, Athens, Greece PURPOSE: The purpose of this study was to report the development, management, and follow up of tamponading uremic pericardial effusion in critically ill patients with acute renal failure. SETTING: The setting for this study was an adult, 24-bed tertiary multidisciplinary intensive care unit (ICU) of a university hospital. PATIENTS: The subjects were 5 critically ill patients with multiple organ failure including acute renal failure (ARF) that was slow to resolve. RESULTS: Renal involvement was attributed to renal hypoperfusion, sepsis and myoglobinuria. Con- tinuous veno-venous hemofiltration (CVVH) was instituted early during hospitalization in 4 cases and lasted for 35 to 48 days; renal replacement therapy was not used in 1 case. Tamponade developed late in the course of ARF, after CVVH was discontinued in the 4 cases and was effectively managed with percutaneous pericardiocentesis under echocardiography and continuous catheter drainage of the peri- cardial sac for 48 to 72 hours. Hemorrhagic fluid (Hb 2.2-5.9 g/dL) with lymphocyte predominance was detected. Transient constrictive-like pericarditis findings were present in all patients after the procedure. All patients were discharged from the hospital in a good condition with normal serum and creatinine levels; 1-year follow up showed a normal echocardiogram. CONCLUSION: Awareness for the possibility of hemorrhagic pericarditis and cardiac tamponade is needed in ICU patients with ARF slow to resolve. Transient constrictive-like pericarditis may present after pericardiocentesis. (Heart Lung® 2004;33:55-60.) INTRODUCTION Uremic pericarditis is clinically detected in 13% of patients with chronic renal failure requiring chronic dialysis. 1 However, uremic pericarditis has been occasionally reported during acute renal fail- ure (ARF); 2,3 moreover, cardiac tamponade is a quite unexpected complication. 4 Currently, patients in intensive care units with multiple organ failure, including ARF, are routinely treated with continuous hemofiltration; 5 an association between uremic pericarditis progressing to tamponade and ARF has been observed in this setting. 6 To our knowledge, the data on the diagnostic approach, management, and follow up of uremic pericarditis and tamponade caused by ARF are scarce. In a period of 4 years in our intensive care unit (ICU), 5 patients with multi- ple organ failure developed uremic cardiac tampon- ade in the course of prolonged, although temporary, ARF. Transient constrictive-like pericarditis was ob- served after successful echo-guided pericardiocen- tesis. PATIENTS/RESULTS The main clinical and biochemical findings are presented in Table I; significant similarities were noted among these patients. In case 4, chronic cholangitis was attributed to a long intestinal loop of a gastric by-pass, performed 1 year earlier for morbid obesity, leading in intesti- nal stasis and probably bacterial translocation. Longstanding sepsis (the patient suffered continu- ous low-grade fever for 1 year with repeated hospital admissions and continuous use of antibiotics) was improved after surgical modification of gastric by- pass. In this patient disseminated intravascular co- From the Department of Critical Care and Pulmonary Services, University of Athens Medical School, Evangelismos Hospital, Athens, Greece. Reprint requests: Epaminondas Zakynthinos, MD, Critical Care Department, Evangelismos Hospital, 45-47 Ipsilantou St, 10675, Athens, Greece. 0147-9563/$30.00 Copyright © 2004 by Elsevier Inc. doi:10.1016/j.hrtlng.2003.10.008 HEART & LUNG VOL. 33, NO. 1 www.heartandlung.org 55