We present an unusual cause of tamponade-like presentation in a patient undergoing anesthesia. We briefly discuss the related pathophysiology and the need for vigilance in maintaining a broad differential diagnosis for critical events occurring in the operating room (OR). The patient gave written consent for publication of this report. A 76-yr-old male presented to hospital with sudden acute onset of abdominal pain and nausea. He was hemo-dynamically stable in the emergency department where blood tests revealed an elevated lactate level (3.4 mmoL-L~(-1). Computed tomography of the patient's abdomen showed a left diaphragmatic hernia defect and small bowel herniation. He was treated with antibiotics and fluid resuscitation by the surgical team while a plan for surgery was being formulated with the concern for potential bowel ischemia. The patient's condition acutely deteriorated on the surgical floor. He developed increasing oxygen requirements and became hypotensive. Repeat investigations showed a serum lactate of 10.5 mmoL-L~(-1) with a blood pH of 7.19. The patient was transferred to the OR for emergency exploratory laparotomy and possible left thoracotomy for reduction of a suspected incarcerated paraesophageal hernia with bowel ischemia.
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