Clinical scenario-sudden hypotension following pneumonectomy

[Gern Blansten]

Hypothetical patient:
65 yr old male with history of HTN, ASCVD, COPD, and lung CA. Uneventful right pneumonectomy. Extubated uneventfully in OR and transported in stable condition to ICU with A-line in place. ICU nurse calls asking for treatment for severe nausea 3 hours post op. Patient then has retching episode moments later and develops sudden hypotension with complaints of chest pain and rapid onset of cyanosis.
What happened? What will you do?

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[proman]

Start cussing.

 

[jwk]

Start cussing.

That too!

 

[deleted126335]

Take the chest tube off suction that was just recently hooked up.

 

[RT2MD]

MS 2.999 attempt at this:

Sounds like the retching episode might have caused enough increased pressure to pop whatever was holding the bronchus closed (staples? sutures?) partly open. The development of severe hypotension/chest pain makes me think that it is essentially functioning like a tension pneumo. I am assuming that a tension pneumo could cause immediate cyanosis as well (probably something I should be sure of as a former RT).

What are breath sounds like? Tracheal deviation? Other vitals?

I would assume that the patient would have a chest tube in? Is it clamped? If he has a chest tube in, and it is to suction/water seal, I would assume that the tube is incorrectly placed or is occluded. Would this be an occasion to "strip" the tube? If rapid attempts to restore patency of the chest tube were unsuccessful, and I was sure that the problem was a tension pneumo, either another tube would have to be placed emergently or a needle decompression would be need to be done.

Then I'd call surgeon dude/dudette to see if we need to go back to the OR.... or I would grab the knife out of that animated avatar and open him up in the ICU right there.

If I'm right or wrong, I'd probably also start cussing.

 

[RT2MD]

Take the chest tube off suction that was just recently hooked up.

Uh-oh... I might not be right... 😎

 

[Gern Blansten]

The xray tech happened to be there and was getting a post op film anyway and he shoots you this digital copy of the CXR.

Does that change your ideas? Ten minutes have now passed and the patient continues to decompensate with hypotension and hypoxia and he begins to show signs of SVC syndrome. He is now unconscious and unarousable. Intubation and ventilation provide no improvement. No changes or manipulations in the chest tube have occurred. As expected, breath sounds are absent in the right lung field.
Who thinks you should call the OR to tell them you are on the way?

 

[RT2MD]

The xray tech happened to be there and was getting a post op film anyway and he shoots you this digital copy of the CXR.

Does that change your ideas? Ten minutes have now passed and the patient continues to decompensate with hypotension and hypoxia and he begins to show signs of SVC syndrome. He is now unconscious and unarousable. Intubation and ventilation provide no improvement. No changes or manipulations in the chest tube have occurred. As expected, breath sounds are absent in the right lung field.
Who wants to call the OR to tell them you are on the way?

I'm a little confused by this CXR. The right hemi diaphragm is elevated, which I would think would be expected in a right pneumonectomy... and I would think that it would be pushed down in the event of a tension pneumo... and what the heck is up with his heart? I also don't see a chest tube... but there is an ETT! 😀

 

[Gern Blansten]

MS 2.999 attempt at this:

Sounds like the retching episode might have caused enough increased pressure to pop whatever was holding the bronchus closed (staples? sutures?) partly open. The development of severe hypotension/chest pain makes me think that it is essentially functioning like a tension pneumo. I am assuming that a tension pneumo could cause immediate cyanosis as well (probably something I should be sure of as a former RT).

What are breath sounds like? Tracheal deviation? Other vitals?

I would assume that the patient would have a chest tube in? Is it clamped? If he has a chest tube in, and it is to suction/water seal, I would assume that the tube is incorrectly placed or is occluded. Would this be an occasion to "strip" the tube? If rapid attempts to restore patency of the chest tube were unsuccessful, and I was sure that the problem was a tension pneumo, either another tube would have to be placed emergently or a needle decompression would be need to be done.

Then I'd call surgeon dude/dudette to see if we need to go back to the OR.... or I would grab the knife out of that animated avatar and open him up in the ICU right there.

If I'm right or wrong, I'd probably also start cussing.

Good differential, almost there. I added a CXR to assist.

 

[Gern Blansten]

I'm a little confused by this CXR. The right hemi diaphragm is elevated, which I would think would be expected in a right pneumonectomy... and I would think that it would be pushed down in the event of a tension pneumo... and what the heck is up with his heart? I also don't see a chest tube... but there is an ETT! 😀

Yeah, what's up with his heart? Did the xray tech reverse the image?

 

[RT2MD]

Yeah, what's up with his heart? Did the xray tech reverse the image?

I don't think so.. it appears as though there is an area of no lung markings on the upper right lobe area, which would make sense if it had been removed. 😎

This is obviously a case of dextrocardia, situs inversus... or Kartagener Syndrome!

In all honesty, I have no idea. I was trying to figure out how the operation could cause a CXR like that, but I think it is beyond me.

 

[lushmd]

The xray tech happened to be there and was getting a post op film anyway and he shoots you this digital copy of the CXR.

Cardiac torsion/herniation S/P pneumonectomy

Who thinks you should call the OR to tell them you are on the way?

I do. Now.

 

[doctor712]

Grabbed a case report of Cardiac Torsion s/p pneumonectomy for the "readers" in the world out there...

I can't get the full paper at home, so, I'm wondering, when chest is left open, post op, the heart torques to the right side of the chest????? Can someone explain the process to me as part of this thread.

Very interesting.

http://www.ncbi.nlm.nih.gov/pubmed/1554288

D712

 

[deleted126335]

Saw one of these a few years ago. Happened right after hooking up a chest tube to suction. Resolved with d/c ing suction.

 

[lushmd]

Cardiac herniation following pneumonectomy occurs due to an intrathoracic pressure disturbance (i.e. positive pressure ventilation, operative side down, increased intragastric pressure as in this case with coughing, increased negative pressure on operative side as Dr. Doze was referring to, etc...) that promotes herniation of the heart through a pericardial defect (which may be created depending on the type of pneumonectomy). The hemodynamic effects described in the OP occur due to this right sided herniation and torsion. BTW, the chest is closed.

Refer to this case report for a reasonable discussion.

 

[Idiopathic]

good case - this happens, and usually the first treatment of hypotension is to reverse whatever the chest tube is doing (i.e. either sucking or not sucking) as pneumo/hemo could be occurring as well.

 

[Gern Blansten]

Pretty rare complication as best I can tell. Lethal very quickly if not recognized and corrected.
Does anybody know if positioning post op can influence whether or not it occurs? Seems logical that it would be less likely to occur if placed with pneumonectomy side up, but I have never seen it written about.

 

[Bertelman]

nice case.

 

[Gern Blansten]

Cardiac herniation following pneuomonectomy occurs due to an intrathoracic pressure disturbance (i.e. positive pressure ventilation, operative side down, increased intragastric pressure as in this case with coughing, increased negative pressure on operative side as Dr. Doze was referring to, etc...) that promotes herniation of the heart through a pericardial defect (which may be created depending on the type of pneuomectomy). The hemodynamic effects described in the OP occur due to this right sided herniation and torsion. BTW, the chest is closed.

Refer to this case report for a reasonable discussion.

Good job. Thanks for posting the case report.

 

[sevoflurane]

Although incredibly rare...

Nice case Gern!

Love that xray.

 

[lushmd]

Thanks for posting the case Gern.

 

[RT2MD]

Great case, thanks for posting!!!

 

[Idiopathic]

Pretty rare complication as best I can tell. Lethal very quickly if not recognized and corrected.
Does anybody know if positioning post op can influence whether or not it occurs? Seems logical that it would be less likely to occur if placed with pneumonectomy side up, but I have never seen it written about.

yes, so they should not be operative side down, should not have excessive suction, and you should aggressively treat coughing/retching.

 

[Doctor4Life1769]

Great case! Thank you!