Post-Pneumonectomy Complications Flashcards by I A

Mortality for pneumonectomy

3-12%

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Mortality increased for Right or Left pneumonectomy

Right sided pneumonectomy

Primarily due to higher incidence:
- BPF
- empyema
- pulmonary edema

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Risk factors for mortality after pneumonectomy

Right sided pneumonectomy
Completion pneumonectomy
older age
induction therapy
resection for infectious or inflammatory diseaes
extended procedures
- carinal pneumonectomy
- extrapleural pneumonectomy

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Morbidity after pneumonectomy

15-75%

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Most frequent complications after pneumonectomy

Respiratory failure
PNA
BPF
empyema
arrhythmia (AF)
MI
PE

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5 important complications associated with pneumonectomy

Post-pneumonectomy syndrome
Cardiac herniation
Post-penumonectomy pulmonary edema
BPF
Empyema

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Progressive mediastinal shift after pneumonectomy

Post-pneumonectomy sydrome

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Etiology of post-pneumonectomy syndrome

Stretching or compression of trachea or remaining bronchus by PA, Ao, or vertebral column

Theoretical etiologies:
- hyperinflation of remaining lung
- hyperplasia
- size of pneumonectomy space
- elasticity of mediastinal tissues
- chest wall or diaphragmatic changes

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Post-pneumonectomy syndrome more common after pneumonectomy of right OR left side?

Right sided pneumonectomy

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Long-term effects of post-pneumonectomy syndrome

Severe respiratory compromise
Tracheobronchial malacia
Recurrent infections
Bronchiectasis
Parenchymal destruction

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Age group at higher risk for post-pneumonectomy syndrome

Children (present early)

(Adults develop late sx: dyspnea, stridor, recurrent infections, orthopnea)

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Dx test of choice for post-pneumonectomy syndrome

Bronchoscopy

CT chest

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TOC for post-pneumonectomy syndrome

Thoractomy with placement of prosthetic device (silicone breast implant) in pneumonectomy space to restore mediastinal anatomic position and relieve airway obstruction

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Most significant complication after intrapericardial pneumonectomy

Caridac herniation

Rare
Equal after right or left pneumonectomy

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Surgical technique to decrease risk of cardiac herniation after left sided intrapericardial pneumonectomy

Open pericardium all the way inferiorly to the diaphragm

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MOA of cardiac herniation (right side)

torsion of LV anteriorly and torsion to the right through the defect (occludes SVC and IVC inflow)

MOA of cardiac herniation (left side)

LV herniation trough defect with strangulation (impariment of diastolic, systoic and coronary perfusion)

Mortality rate associated with cardiac herniation after pnuemonectomy

~ 50%

Occurs wtihin first 72 hours
Triggered by change in patient position

Presentation of cardiac herniation

Fist 72 hrs postop
Recent change in patient position
Cyanosis, elevated CVP, hypotension, tachycardia
Displaced cardiac impulse
Rapid clinical deterioration

TOC of cardiac herniation (right side)

Place patient left side down (immediately)
Emergent return to OR for redo thoracotomy and patch closure of pericardial defect

Clinical presentation of post-pneumonectomy pulmonary edema

Rapidly progressive dyspnea, hypoxemia, and CXR e/o pulmonary edema in patient with normal PFTs and unremarkable 12-24 hour postoperative course after right pneumonectomy

Incidence of post-pneumonectomy pulmonary edema

~ 2-5%

Mortality associated with post-pneumonectomy pulmonary edema

~60-90%

Risk factors for post-pneumonectomy pulmonary edema

Right sided pneumonectomy
Extensive resection (carinal pneumonectomy)

MOA of post-pneumonectomy pulmonary edema

Similar to ARDS (endothelial injury) with an increased gradient across the pulmonary microcirculation (i.e. hyperpermiability)

Factors thought to contribute to post-pneumonectomy syndrome

* Excessive fluid administration * Disruption of lymphatics draining remaining lung * Immunologic reaction to blood products (FFP) * Extent and duration of opertaion * Use of underwater seal drainage system vs. balanced system * Mechanical factors (hyperinflation, air blocking)

Dx w/u for post-pneumonectomy pulmonary edema

Invasive right heart monitoring CT Pan-cultures Bronchoscopy

Tx post-pneumonectomy pulmonary edema

* IVF restriction * Early use of diurectics * Pain control * Pressors for hypotension * Avoidance of barotrauma (PC ventilation) * iNO * Steroids (controversial)

Incidence of BPF afgter pneumonectomy

1-10%

Mortaliy associated with BPF after pneumonectomy

30-50%

RF for BPF after pneumonectomy

* Right sided pneumonectomy * Completion pneumonectomy * Resection for inflammation/infection (esp TB with positive sputum) * Prior mediastinal/hilar XRT * Prolonged mechanical ventilation * DM * Post-pneumonectomy empyema * Residual tumor at bronchial stump * Stump devascularization, incomplete closure, long bronchial stump * Old age * Steroid use, malnutrition, induction chemo and XRT * *

BPF eary after surgery (1-2 days) usually due to

Technical factors (devascularization, incomplete closure, long stump)

Presentation of early BPF

* Massive air leak * Progressive SQ air * Respiratory insufficiency

Presentation of BPF later in postoperative course

Due to inadequate healing of broncial stump Fever and/or productive cough Risk for flooding remaining lung (place patient with operative side down, head up, and immediate drainage of pleural space with tube thoracostomy or redo thoracotomy)

Presentation and diagnosis of occult BPF

Most common form Asymptomatic or minimally symptomatic (fall in plural space fluid) Dx: bronchoscopy (maybe methylene blue injection into pneumonectomy space) (alternate: inhaled radionuceotide)

TOC of occult BPF

Close observation (if asymptomatic) Prompt drainage of pleural space (signs or syptoms of infection)

TOC of clinically evident BPF

* Early presentation (within 2 weeks): * Abx * Reoperation, repair and coverage of stump (omentum, pericardial fat, muscle) * Open drainage if severe empyema * Late presentaiton (\> 2 weeks): * Abx * Pleural space drainage (tube or open drainage) * Cleansing of pleural space * Closure of bronchial stump with coverage * If unable to close, transpose muscle flap between divided ends to avoid re-fistulization * Sterilization of pleural space (Clagett procedure) * If fails, pleural space obliteration with muscle flaps

Incidence of empyema after pneumonectomy

2-16% (5-7% in most series)

Dx and TOC of post-pneumonectomy empyema

* Dx: sampling of pleural fluid * TOC: * Abx and drainage * Early empyema without BPF: * VATS drainage, irrigation, and Abx * Large empyema without BPF: * Open drainage * Sterilizaiton of pleural space (Clagget procedure) * Pleural space obliteration with flaps * Thoracoplasty