Non-intubated VATS under combined serratus anterior plane block for hemodynamically fragile post-CABG delayed pericardial effusion: a case report

BACKGROUND: Delayed postoperative pericardial effusion after coronary artery bypass grafting (CABG) may pose a significant risk in patients with limited cardiac reserve because of impaired ventricular filling and potential hemodynamic instability. Positive pressure ventilation (PPV) may reduce venous return and cardiac output in preload-dependent patients. CASE PRESENTATION: A 73-year-old male who had undergone CABG 10 days earlier presented with symptomatic delayed postoperative large pericardial effusion. Given hemodynamic fragility, a physiology-guided anesthetic plan that avoided intubation and PPV was implemented. Non-intubated video-assisted thoracoscopic surgery (NI-VATS) with combined serratus anterior plane block (C-SAPB, deep and superficial) under spontaneous ventilation was performed. Sedation was achieved with dexmedetomidine (RASS 0 to - 1). Total procedural time was 40 min. Approximately 450 mL of pericardial and 500 mL of pleural fluid were drained. Hemodynamics remained stable (MAP 66-100 mmHg). Mild hypercapnia (PaCO₂ 46 mmHg) occurred without metabolic derangement. CONCLUSION: NI-VATS under C-SAPB may represent a potential physiology-preserving option in carefully selected high-risk post-CABG patients with delayed pericardial effusion, particularly when avoidance of PPV is considered clinically advantageous.