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Sun Feb 24 04:42:38 GMT 2008

I believe that pneumonectomy in a patient who is in shock is a large
part of the problem. This patient is primed for systemic
hyperinflammation--and the second hit may take multiple forms--blood
transfusion, crytalloid over-resuscitation, volutrauma for the
ventilator, etc. In the OR, I have witnessed acute right heart failure
with hilar cross-clamping and pneumonectomy--and have wondered if RV
unloading with prostacyclin or inhaled NO would be beneficial in this
setting.

Pat

Patrick J. Offner MD MPH
Chief, Surgical Critical Care
St Anthony Central Hospital

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of MARK FORREST
Sent: Thursday, February 21, 2008 2:00 PM
To: Trauma &amp; Critical Care mailing list
Subject: Re: Post pneumonectomy

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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