eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Cardiology
Pericardial Effusion, Malignant: Treatment & Medication
Updated: Jul 24, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Medical care is dictated mainly by the general condition of the patient and the underlying malignancy.
- Remember that almost 50% of patients with symptomatic pericardial effusion and neoplastic disease have a nonmalignant cause, such as radiation-related, idiopathic, infectious (including tuberculous and fungal), and lymphatic obstruction.
- Intrapericardial administration of drugs, such as cisplatin, has been attempted and can be of significant value.
Surgical Care
- Open surgical drainage (pericardiotomy)
- The safety and effectiveness of surgical drainage of pericardial fluid via pericardiectomy (compete or partial) or the creation of a pericardial window are well recognized.
- This procedure removes fluid that is excessively thick. Perform open surgical drainage if purulent pericarditis is present. Obtain biopsy specimens from the pericardium and epicardium.
- Total pericardiectomy may be required, especially in the presence of a thickened pericardium that has a constricting effect.
- Thoracotomy may be required to arrive at a complete diagnosis.
Consultations
- Pediatrician
- Pediatric cardiologist
- Pediatric oncologist
- Radiologist
- Nuclear medicine specialist
- Cardiothoracic surgeon
- Physiotherapist
- Occupational therapist
- Specialist nurse
- Family physician
Diet
- No special diet requirements are necessary.
Activity
- Restrict activity only to the limit of intolerance.
Medication
Hemodynamic support is of some value until drainage of pericardial fluid can be accomplished. Pericardiocentesis and intrapericardial sclerosis are effective therapies for malignant pericardial effusions that recur. Intrapericardial administration of drugs, such as cisplatin, can be important. Use anti-inflammatory drugs for viral pericarditis.
Nonsteroidal anti-inflammatory drugs
These agents are analgesics that offer anti-inflammatory action. They have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action inhibits cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may also occur, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.
Ibuprofen (Advil, Motrin, Ibuprin)
Propionic acid derivative that reduces the formation of inflammatory mediators by enzyme inhibition.
Adult
1.6-2.4 g/d PO divided qid
Pediatric
40 mg/kg/d PO divided qid; not to exceed 2.4 g/d
May decrease effects of loop diuretics; coadministration with anticoagulants may increase PT (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate and phenytoin toxicity; probenecid may increase toxicity of NSAIDs; may decrease effect of antihypertensive agents because of fluid retention
Documented hypersensitivity, peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Pregnancy category D in the third trimester; caution in CHF, hypertension, and decreased renal and hepatic function; anticoagulation abnormalities or during anticoagulant therapy
Naproxen (Aleve, Anaprox, Naprosyn)
Propionic acid derivative that reduces the formation of inflammatory mediators by enzyme inhibition.
Adult
0.5-1 g/d PO divided qd/bid
Pediatric
<2 years: Not established
>2 years: 10 mg/kg/d PO divided bid; not to exceed 1 g/d
May decrease effects of loop diuretics with coadministration; coadministration with anticoagulants may increase PT (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate and phenytoin toxicity; probenecid may increase toxicity of NSAIDs; may decrease effect of antihypertensive agents because of fluid retention
Documented hypersensitivity, peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Pregnancy category D in the third trimester; caution in CHF, hypertension; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia rarely occurs, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Diclofenac sodium (Cataflam)
Possesses properties similar to propionic acid derivatives and reduces the formation of inflammatory mediators by enzyme inhibition. Cataflam tablets are immediate-release.
Adult
75-150 mg/d PO/PR divided bid/tid
Pediatric
1-3 mg/kg/d PO/PR divided bid/tid; not to exceed 25 mg/d for children aged 2-5 years and 50 mg/d for those aged 6-10 years
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; fluid retention caused by NSAIDs may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding) may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, and those at high risk of bleeding; perioperative pain with CABG
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Pregnancy category D in the third trimester; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low WBC counts rarely occur and usually return to normal in ongoing therapy; discontinuation of therapy may be necessary if leukopenia, granulocytopenia, or thrombocytopenia persists
Indomethacin (Indocin)
Behaves like the propionic acid derivatives and inhibits the formation of inflammatory mediators. Rapidly absorbed; metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation; inhibits prostaglandin synthesis.
Adult
50-200 mg/d PO divided tid/qid
Pediatric
0.3-3 mg/kg/d PO divided tid/qid
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; may decrease effects of beta-blockers, hydralazine, and captopril; may decrease diuretic effects of furosemide and thiazides; coadministration with anticoagulants may prolong PT (monitor and watch for signs of bleeding); may increase risk of methotrexate toxicity, which can manifest as stomatitis, bone marrow suppression, or nephrotoxicity; coadministration may increase phenytoin levels; probenecid may increase toxicity of NSAIDS
Documented hypersensitivity; GI bleeding; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Pregnancy category D in the third trimester; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur (discontinue if leukopenia, granulocytopenia, or thrombocytopenia is persistent)
Corticosteroids
These agents elicit anti-inflammatory and immunosuppressive properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli.
Prednisone (Deltasone, Orasone)
Used for patients with severe inflammatory pericardial effusions or for those in whom initial treatment with NSAIDs has failed.
Adult
10-60 mg/d PO every am
Pediatric
1-2 mg/kg/d PO every am
Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; viral infection, peptic ulcer disease, hepatic dysfunction, connective tissue infections, and fungal or tubercular skin infections; GI bleeding or ulceration
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use
More on Pericardial Effusion, Malignant |
| Overview: Pericardial Effusion, Malignant |
| Differential Diagnoses & Workup: Pericardial Effusion, Malignant |
 Treatment & Medication: Pericardial Effusion, Malignant |
| Follow-up: Pericardial Effusion, Malignant |
| Multimedia: Pericardial Effusion, Malignant |
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Further Reading
Keywords
pericardial effusion, malignant pericardial effusion, dropsy of pericardium, mediastinal mass, nodular tumor deposits, lymphatic spread, diffuse pericardial thickening from tumor infiltration, chronic myelomonocytic leukemia, intrapericardial extramedullary hematopoiesis, preleukemic conditions, blast crisis, chronic myeloid leukemia, obstruction of lymphatic drainage, pericarditis, effusive-constrictive pericarditis, cardiac tamponade, asthma, emphysema, pleural effusion, rhabdomyoma, fibroma, heart failure, fetal hydrops, hydrops fetalis, pericardial mesothelioma, angiosarcoma, liposarcoma, lymphoma, rhabdomyosarcoma, tuberous sclerosis, pheochromocytoma, Kaposi sarcoma, HIV infection, non-Hodgkin lymphoma, neuroblastoma, ganglioneuroblastoma, Wilms tumor, Hodgkin lymphoma, adenocarcinoma, leiomyosarcoma, Burkitt lymphoma
