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cardio.cardiac-tamponade.uremic.v1

Cardiac tamponade — uremic pericardial effusion

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.cardiac-tamponade.core.v1 — narrowed to uremic pericardial effusion (ESRD on inadequate dialysis OR pre-dialysis CKD stage 5). Inherits drainage + bridge regimen from parent via routing; specializes for uremic-specific first-line therapy: intensified HD daily × 5-7d with heparin-free or regional citrate (~70% effusion resolution per ESC 2015 §Uremic Pericarditis + Wood Am J Nephrol 1995); pericardiocentesis reserved for hemodynamic compromise OR effusion >250 mL not improving with HD; uremic platelet dysfunction prophylaxis (desmopressin 0.3 µg/kg + protamine if recent HD heparin) per Banerjee AJKD 2014; NSAIDs AVOIDED, colchicine HOLD if eGFR <30 (limited evidence + bleeding/AKI risks); nephrology + cardiology shared care mandatory per KDIGO 2024. Manifest pointer reuses cardio.cardiac-tamponade.core.v1 manifest. Design-brief pointer reuses parent (uremic-specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-14 by shard-06-cardio-acute.

Entry points (4)

  • problem_list
    ESRD on HD + missed sessions OR inadequate Kt/V + new dyspnea + JVD (ESC 2015 §Uremic Pericarditis)
    esrd_with_missed_dialysis_and_dyspnea
  • problem_list
    Pre-dialysis CKD stage 5 (eGFR <15) with pericardial friction rub or pleuritic chest pain (Banerjee AJKD 2014)
    pre_dialysis_ckd5_with_pericardial_friction_rub
  • imaging
    Echo: pericardial effusion ± RV diastolic collapse / IVC plethora in dialysis patient (ESC 2015 Class I)
    echo_pericardial_effusion_in_dialysis_pt
  • symptom
    Hypotension during routine HD in patient with known pericardial effusion → tamponade physiology unmasked by ultrafiltration-induced preload reduction (ESC 2015)
    hypotension_during_hd_in_pt_with_known_effusion

Required inputs (9)

  • agerequired
    demographic • used at CONTEXT
    Older ESRD patients have higher procedural risk + comorbidity burden (KDIGO 2024)
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension is part of Beck triad; ESRD patients often have baseline orthostasis from autonomic dysfunction (Banerjee AJKD 2014)
  • hrrequired
    vital • used at CONTEXT
    Compensatory tachycardia in tamponade physiology (ESC 2015)
  • echorequired
    imaging • used at INITIAL_WORKUP
    Definitive bedside dx — chamber collapse, IVC, swinging heart (ESC 2015 Class I); also assess effusion size (250 mL = drainage threshold per ESC 2015 §Uremic Pericarditis)
  • dialysis_modality_and_adequacyrequired
    history • used at CONTEXT
    HD vs PD vs not-yet-dialyzing; recent Kt/V; missed sessions — drives intensified-HD prescription (KDIGO 2024)
  • bunrequired
    lab • used at INITIAL_WORKUP
    BUN >100 mg/dL strongly associated with uremic pericarditis (Banerjee AJKD 2014); response to HD tracked via BUN trend
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Quantifies CKD stage; sCr trend during intensified HD reflects clearance adequacy (KDIGO 2024)
  • potassiumrequired
    lab • used at INITIAL_WORKUP
    Hyperkalemia common pre-HD; affects HD prescription urgency (KDIGO 2024)
  • plateletsrequired
    lab • used at INITIAL_WORKUP
    Uremic platelet dysfunction (qualitative defect) increases bleeding risk during pericardiocentesis even with normal count (Banerjee AJKD 2014)

12-phase flow (9)

  1. 1FRAME
    Uremic tamponade — intensified dialysis is FIRST-LINE; pericardiocentesis only for hemodynamic compromise OR effusion >250 mL not improving with HD (ESC 2015 §Uremic Pericarditis)
    inputs: sbp
    advance: uremic-context tamponade physiology suspected
  2. 2ENTRY
    Recognize Beck triad in dialysis or pre-dialysis CKD5 patient; rule in uremic etiology vs viral vs autoimmune vs malignant overlay (Banerjee AJKD 2014)
    inputs: age
    advance: CKD/ESRD context confirmed + uremic etiology likely
  3. 3CONTEXT
    Document dialysis modality, adequacy (Kt/V), recent missed sessions, vascular access, BUN/Cr trend, transplant candidacy (KDIGO 2024)
    inputs: dialysis_modality_and_adequacy
    advance: dialysis context fully captured
  4. 4RED_FLAGS
    Obstructive shock physiology (ESC 2015); separately screen for HD-induced hypotension unmasking borderline tamponade (Banerjee AJKD 2014)
    inputs: sbp, hr
    advance: shock recognized → drainage prepared OR intensified HD initiated based on hemodynamic trajectory
  5. 5INITIAL_WORKUP
    STAT echo, ECG, CXR, troponin, BMP including BUN/Cr/K/PO4/Ca, CBC (uremic platelet dysfunction), coags (heparin from recent HD), pre-HD labs (KDIGO 2024)
    inputs: echo, bun, creatinine, potassium, platelets
    actions: panel.cardiac, panel.renal, panel.coag
    advance: echo confirms tamponade physiology + uremia quantified
  6. 6DIFFERENTIAL
    Confirm uremic etiology via fluid analysis (typically hemorrhagic exudate; cell count, glucose, LDH, AFB, cytology to exclude malignant overlay; Sagristà-Sauleda EHJ 2002 PMID 12122206)
    advance: fluid sent + uremic etiology supported by clinical + lab pattern
  7. 7TREATMENT
    Step 1 intensified HD (daily × 5-7 days) WITHOUT systemic heparin → resolves ~70% effusions (ESC 2015 §Uremic Pericarditis; Wood Am J Nephrol 1995); Step 2 pericardiocentesis if effusion >250 mL + hemodynamic compromise OR no response to 5-7d intensified HD; Step 3 pericardial window if recurrent (Banerjee AJKD 2014)
    inputs: sbp
    advance: HD intensification initiated +/- pericardial drainage performed
  8. 8DISPOSITION
    CCU/ICU if hemodynamic compromise; nephrology + cardiology co-management (KDIGO 2024); transplant evaluation if eligible
    advance: multidisciplinary disposition confirmed
  9. 9MONITORING
    Re-accumulation surveillance (echo q24h × 7d then weekly), BUN/Cr trend during intensified HD, CRP trend, fluid analysis follow-up (ESC 2015 §Follow-up)
    actions: panel.pleural
    advance: HD response documented + effusion resolution trajectory established