Post pneumonectomy pulmonary oedema

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Karim,

I have seen something similar many years ago in a patient with  
congenital emphysema in one lung only. He had made it to his early  
60's, but his symptoms were so severe he had it out. To give you some  
idea, when I lay him flat to examine his abdomen he got up, went to  
the sink, and appeared to vomit. This was coughing for him! Two hours  
post-op he did exactly the same as your patient.

What is happening here is, in a way, the converse of VQ miss-match.  
Normally the cardiac output is divided between the lungs. Post-op all  
of it has to go through the smaller lung. It's a case of too much  
being stuffed into too small a space too quickly. At some point the  
compensatory mechanisms will overload, and you get the result you  
witnessed. Because your patient was young he was able to compensate  
for some time, where as mine was older with less reserve (and a big  
shunt suddenly removed) and did it in a couple of hours.

Lesson to be learn ed? Next time I would float a PA catheter, and  
control the PA pressure before the decopensation point. Fluid  
strategies I would consider would be on the dry side, even if the base  
excess is slow to correct. Drug I would consider include milrinone,  
and a combination of GTN and norepinephrine. I would then wean these  
over several days, guided by PA pressure, to give the pulmonary  
vasculature etc. time to adapt. This sounds crazy in the light of the  
normal management of trauma patients, but this is not a normal  
situation and fortunately very rare.

Hope this helps,

Guy

Quoting Karim Brohi <karim at trauma.org>:

> 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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