Pericardial effusions in children have multiple causes and variable presentations. Cardiac tamponade occurs when the heart chambers become externally compressed and ultimately cardiac output is compromised. The classical signs of cardiac tamponade include jugular venous distention, muffled heart sounds, and systemic hypotension (“Beck’s triad”); however, these are rarely all present. As cardiac output is dependent on preload and heart rate, the anesthetic goal is to avoid cardiac depression, maintain sympathetic outflow, and avoid a decrease in preload. If the effusion is amenable to percutaneous drainage, ideal anesthetic management includes sedation and analgesia with local anesthetic, while keeping the patient spontaneously breathing. If an open procedure is required, it is advisable to perform a “staged” anesthetic and surgical approach in which sedation, analgesia, and local anesthetic are administered to drain the effusion percutaneously before inducing general anesthesia and starting positive-pressure ventilation. As in most emergency situations, the risks of pulmonary aspiration and the chosen anesthetic techniques must be weighed against the urgency of intervention.

During fetal development, little blood flows through the lungs due to high pulmonary vascular resistance. After birth, pulmonary vascular resistance is initially elevated and then decreases over the first few days of life. In normal infants the ductus arteriosus is not needed after birth and begins to functionally close during the first 24–72 hours after birth. It is anatomically closed between the third and fourth week of life. In infants with critical pulmonary valve stenosis, the amount of antegrade blood flow through the pulmonary valve to the pulmonary arteries is limited, and therefore the major source of source of pulmonary blood flow is provided via the ductus arteriosus. As it closes, if antegrade blood flow through the critically stenosed pulmonic valve is not sufficient infants become hypoxemic and may require institution of prostaglandin E1 to maintain ductal flow. Balloon pulmonary valvuloplasty in the cardiac catheterization laboratory is the treatment of choice for the typical dome-shaped valve characteristically seen in pulmonary stenosis. This chapter describes the perioperative considerations and management of an infant with critical pulmonary stenosis undergoing balloon valvuloplasty in the catheterization laboratory.