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ABTS - Thoracic Surgery Notecards > Post-Pneumonectomy Complications > Flashcards

Post-Pneumonectomy Complications Flashcards

1
Q

Mortality for pneumonectomy

A

3-12%

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2
Q

Mortality increased for Right or Left pneumonectomy

A

Right sided pneumonectomy

  • Primarily due to higher incidence:
    • BPF
    • empyema
    • pulmonary edema
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3
Q

Risk factors for mortality after pneumonectomy

A
  • 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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4
Q

Morbidity after pneumonectomy

A

15-75%

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5
Q

Most frequent complications after pneumonectomy

A
  • Respiratory failure
  • PNA
  • BPF
  • empyema
  • arrhythmia (AF)
  • MI
  • PE
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6
Q

5 important complications associated with pneumonectomy

A
  1. Post-pneumonectomy syndrome
  2. Cardiac herniation
  3. Post-penumonectomy pulmonary edema
  4. BPF
  5. Empyema
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7
Q

Progressive mediastinal shift after pneumonectomy

A

Post-pneumonectomy sydrome

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8
Q

Etiology of post-pneumonectomy syndrome

A

​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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9
Q

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

A

Right sided pneumonectomy

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10
Q

Long-term effects of post-pneumonectomy syndrome

A
  • Severe respiratory compromise
  • Tracheobronchial malacia
  • Recurrent infections
  • Bronchiectasis
  • Parenchymal destruction
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11
Q

Age group at higher risk for post-pneumonectomy syndrome

A

Children (present early)

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

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12
Q

Dx test of choice for post-pneumonectomy syndrome

A

Bronchoscopy

CT chest

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13
Q

TOC for post-pneumonectomy syndrome

A

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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14
Q

Most significant complication after intrapericardial pneumonectomy

A

Caridac herniation

  • Rare
  • Equal after right or left pneumonectomy
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15
Q

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

A

Open pericardium all the way inferiorly to the diaphragm

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16
Q

MOA of cardiac herniation (right side)

A

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

17
Q

MOA of cardiac herniation (left side)

A

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

18
Q

Mortality rate associated with cardiac herniation after pnuemonectomy

A

~ 50%

  • Occurs wtihin first 72 hours
  • Triggered by change in patient position
19
Q

Presentation of cardiac herniation

A
  • Fist 72 hrs postop
  • Recent change in patient position
  • Cyanosis, elevated CVP, hypotension, tachycardia
  • Displaced cardiac impulse
  • Rapid clinical deterioration
20
Q

TOC of cardiac herniation (right side)

A
  • Place patient left side down (immediately)
  • Emergent return to OR for redo thoracotomy and patch closure of pericardial defect
21
Q

Clinical presentation of post-pneumonectomy pulmonary edema

A

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

22
Q

Incidence of post-pneumonectomy pulmonary edema

A

~ 2-5%

23
Q

Mortality associated with post-pneumonectomy pulmonary edema

A

~60-90%

24
Q

Risk factors for post-pneumonectomy pulmonary edema

A
  • Right sided pneumonectomy
  • Extensive resection (carinal pneumonectomy)
25
Q

MOA of post-pneumonectomy pulmonary edema

A

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

26
Q

Factors thought to contribute to post-pneumonectomy syndrome

A
  • 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)
27
Q

Dx w/u for post-pneumonectomy pulmonary edema

A

Invasive right heart monitoring

CT

Pan-cultures

Bronchoscopy

28
Q

Tx post-pneumonectomy pulmonary edema

A
  • IVF restriction
  • Early use of diurectics
  • Pain control
  • Pressors for hypotension
  • Avoidance of barotrauma (PC ventilation)
  • iNO
  • Steroids (controversial)
29
Q

Incidence of BPF afgter pneumonectomy

A

1-10%

30
Q

Mortaliy associated with BPF after pneumonectomy

A

30-50%

31
Q

RF for BPF after pneumonectomy

A
  • 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
  • *
32
Q

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

A

Technical factors

(devascularization, incomplete closure, long stump)

33
Q

Presentation of early BPF

A
  • Massive air leak
  • Progressive SQ air
  • Respiratory insufficiency
34
Q

Presentation of BPF later in postoperative course

A

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)

35
Q

Presentation and diagnosis of occult BPF

A

Most common form

Asymptomatic or minimally symptomatic (fall in plural space fluid)

Dx: bronchoscopy (maybe methylene blue injection into pneumonectomy space)

(alternate: inhaled radionuceotide)

36
Q

TOC of occult BPF

A

Close observation (if asymptomatic)

Prompt drainage of pleural space (signs or syptoms of infection)

37
Q

TOC of clinically evident BPF

A
  • 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
38
Q

Incidence of empyema after pneumonectomy

A

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

39
Q

Dx and TOC of post-pneumonectomy empyema

A
  • 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

ABTS - Thoracic Surgery Notecards (48 decks)

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