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Thu Feb 21 21:00:27 GMT 2008

Intersting this over-inflation theory, because we often used to see a very similar x-ray at 24hrs in postop O-G patients, BUT on the non-surgical side. Traditional anaesthetic teaching recommended ventilating on one lung with 'low to normal' tidal volumes, which inevitably led to over-inflation/distension of the healthy lung and the white out of the lung field the follwoing day. This was inevitably made much worse before we started running them dry, but by reducing the tidal volume and maintining minute ventilation by increasing rate instead, we greatly reduced the barotrama to the 'good' lung. 

As for your case....still waiting for the sheep, pig or guinea pig model that explains it!
Cheers
Mark

Dr Mark Forrest
Consultant in Anaesthetics & Critical Care
Medical Director of Cheshire Fire & Rescue Service
Medical Director of ATACC

----- Original Message ----
From: Karim Brohi <karim at trauma.org>
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Sent: Thursday, 21 February, 2008 12:41:37 AM
Subject: RE: Post pneumonectomy

So it turns out there is a sheep model of this, and some studies suggest
that it is hyper-inflation of the lung that leads to the pulmonary oedema.
(Small studies - certainly not what you'd classify as a flock).  The
attached X-ray is of this patient a couple of hours before the event.  The
film is rotated but there's no gross overinflation of the lung.

The authors of this study recommend balanced suction for the chest tube
drainage rather than free drainage or clamp-release regimens.  Any thoughts
on this?

Thanks

Karim

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Sanjay Gupta MD
Sent: 20 February 2008 20:37
To: Trauma &amp, Critical Care mailing list
Subject: RE: Post pneumonectomy 

One of the reasons why the patients with elective
pneumonectomy do better is, that usually the lung that
is resected is already diseased and a large part of
its function (and blood flow) has already been taken
over by the healthy lung. 

It would be interesting to see what the thoracic
surgeons on the list think about this. 

Sanjay

--- "Robert F. Smith" <rfsmithmd at comcast.net> wrote:

> Back in the day weren't pneumonectomies occasionally
> done for other
> pulmonary disease? Why were the outcomes better in
> more debilitated patients
> with elective surgery?
> 
> Rob Smith
> 
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org]
> On Behalf Of KMATTOX at aol.com
> Sent: Monday, February 11, 2008 10:40 PM
> To: trauma-list at trauma.org
> Subject: Re: Post pneumonectomy pulmonary oedema
> 
> 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?
> 
> 
> 
> 
> 
> **************The year's hottest artists on the red
> carpet at the Grammy 
> Awards. Go to AOL Music.      
>
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> 

Sanjay Gupta
Tel: 412 335 6304

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