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Tue Feb 12 23:31:02 GMT 2008

"I tried really hard not to take the whole lung out.  Should have tried harder."

And then you would have been kicking yourself for losing the guy on the table.  Karim, you are really, really good, but you ain't God.

Just my 2 cents, my friend.

Take care,
Ron

>>> "Karim Brohi" <karim at trauma.org> 2/12/2008 6:20 PM >>>
Thanks Mike.  Seems others on and off the list have had exactly the same
patient.

However I'm not buying any of the explanations so far put forward.  There
was no evidence of a 'cytokine storm' or any other excessive inflammatory
reaction.  White count was normal, CRP returning to normal.  No fever.
Normal coagulation. Literally one minute he was well, the next he had gross
pulmonary oedema, the next he was dead.  I don't buy other causes of ALI
either.  The time course is all wrong.  TRALI has essentially disappeared
since we moved to male-donor plasma.

Pulmonary embolism does not cause pulmonary oedema (duh).

The time-course of this strongly suggests a mechanical or hydrostatic cause.
My best guess explanation is that he had acute right heart failure, which
was undiagnosed.  He remained essentially asymptomatic (young man) until he
developed septal shift and then acute left heart failure.  Other
possibilities still huge MI or cardiac tamponade.  PM will pick these up,
not sure about the acute failure?

I did do a lung-twist intra-op.  Then it became clear he had a tear in the
pulmonary vein as it exited the pericardium, which was worsened by the
twist.  Also the position of the injury meant that the damaged lung was
inaccessible once twisted.  Finally, useful as the twist is, I'm not sure
how this is different from a hilar clamp - unless it's a partial twist and
there is still some perfusion / oxygenation.  I like the idea of developing
a model to explore this.

I tried really hard not to take the whole lung out.  Should have tried
harder.

Karim

From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] 
On Behalf Of Sise, Mike MD
Sent: 12 February 2008 21:19
To: Trauma &amp; Critical Care mailing list
Subject: RE: Post pneumonectomy pulmonary oedema

Karim,

In our San Diego County 20 + year, Trauma Registry we have very very few
survivors of pnuemonectomy. Seems to cross a threshold of severity every
time we do it. Lots of patients successfully managed with extensive partial
lobectomy etc. as I'm sure you've experienced. We always predict death
whenever we take out the entire lung. Pulmonary edema / severe ARDS seen in
many patients and worsening often delayed during initial postop course.

Great question for the members of the list.

Mike Sise

San Diego 

  _____  

From: Mike Smertka [mailto:medic0947969 at yahoo.com] 
Sent: Tue 2/12/2008 3:21 AM
To: Trauma &amp, Critical Care mailing list
Subject: Re: Post pneumonectomy pulmonary oedema

Dr. Mattox,

  Is there anyhting on the market to inhibit the cytokne release. In my
hasty google search all I found were experimental.

  Mike

KMATTOX at aol.com wrote:
  Karim: I have seen this in far too many fit young people. It is far
more common than anyone writes about. Humans with acute cytokine release
simply do not tolerate acute pneumonectomy and CRASH between 12 and 18
hours.
Perhaps should be maimntained on membrane oxygenation and other supporting
mechanisms for 3-5 days. I would suggest you consider a "lung twist" to
damage control the bleeding. Take back to OR at 8-12 hours and reassess,
and then back 8-12 hours to reassess. We need to talk about a good protocol
and a good experimental model.

k

In a message dated 2/11/2008 9:33:47 P.M. Central Standard Time,
karim at trauma.org writes:

Initially did well, extubated at 24 hours, comfortable, haemoserous drainage
from chest tubes. 12 hours later after a couple of transient dips in
saturation developed acute pulmonary oedema, froth coming up the ET tube,
and died within minutes.

Any ideas?

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Post pneumonectomy pulmonary oedema