S/P Pneumonectomy now with Aspergillomas

[VentdependenT]

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50 yr old female with MET=3 and no cardiac dz presents for Aspergilloma recrudescense S/P R Pneumonectomy in 2006. 96% room air with RR of 12. CT shows well loculated 1cm aspergillomas in her LLL. Minimal hilar adnopathy. Tracheobroncheal tree, or what remains, is patent.

She has no systemic signs of infection & no cough.

She is on high dose prednisone and immune modulators for RA (No neck involvement). Hence the Aspergillus.

Plan is for tiny focused wedge resections.

Thoracic Epidural or is this infection a contraindication. Your thoughts please. Risk vs Benefit of someone with One Lung remaining and a neuraxial block VS. standard systemic narcotics/toradol.

 

[Planktonmd]

50 yr old female with MET=3 and no cardiac dz presents for Aspergilloma recrudescense S/P R Pneumonectomy in 2006. 96% room air with RR of 12. CT shows well loculated 1cm aspergillomas in her LLL. Minimal hilar adnopathy. Tracheobroncheal tree, or what remains, is patent.

She has no systemic signs of infection & no cough.

She is on high dose prednisone and immune modulators for RA (No neck involvement). Hence the Aspergillus.

Plan is for tiny focused wedge resections.

Thoracic Epidural or is this infection a contraindication. Your thoughts please. Risk vs Benefit of someone with One Lung remaining and a neuraxial block VS. standard systemic narcotics/toradol.

I have no problem with a thoracic epidural, and I think that the benefit clearly outweighs the risk is this patient who is going to be left with only a part of one lung, so any help you can offer to minimize post op pain would increase her chances of ever leaving the hospital.
Aspergilomas are usually confined to the lung and have minimal general symptoms and rarely spread anywhere else, on the other hand if the patient had invasive systemic aspergilosis (these are critically ill patients and severely immuno-compromised) then you can argue against the epidural because it might contribute to an epidural spread (theoretically), that is clearly not the case here.

 

[Noyac]

Can they do this thorascopically or does it need to be open?

 

[VentdependenT]

Can they do this thorascopically or does it need to be open?

Gotta go open because she only has this one lung. Surgeon will not be able to visualize with VATS with a completely inflated lung.

 

[Noyac]

Gotta go open because she only has this one lung. Surgeon will not be able to visualize with VATS with a completely inflated lung.

Gotcha

 

[VentdependenT]

So is this a relative contraindication or what?

 

[Noyac]

So is this a relative contraindication or what?

Not sure. I'd say it depends on the surgeon and whether or not the pt tolerates the intrathoracic pressure. I have never done a VAS one a pt with one lung.😱 If the pressure was kept real low and the lesion was in a good psition I wonder if it could be done. Personally, I'd just prefer open.

 

[VentdependenT]

Whabout a contraindication to the thoracic epidural noy?

We had to go open anyhoots.

I wanted to put in a thoracic epidural. My attending felt that having aspergillomas was a contraindication to neuraxial because, technically, its an infection. It would be the same as putting a thoracic epidural in someone with walled off tuberculosis granules (gohn complex...is that wtf they are called?).

 

[Noyac]

Whabout a contraindication to the thoracic epidural noy?

We had to go open anyhoots.

I wanted to put in a thoracic epidural. My attending felt that having aspergillomas was a contraindication to neuraxial because, technically, its an infection. It would be the same as putting a thoracic epidural in someone with walled off tuberculosis granules (gohn complex...is that wtf they are called?).

Without systemic signs I don't see a contraindication.

 

[coprolalia]

I wanted to put in a thoracic epidural. My attending felt that having aspergillomas was a contraindication to neuraxial because, technically, its an infection.

I don't think that aspergilloma usually counts as a "systemic" infection, which is often the contraindication, but this patient wasn't febrile with an indication of sepsis, right, which would point to invasive aspergillosis? But, I do hear you about seeding through a "Ghon" complex, but unless it's invasive aspergilloma balls are, by definition, intraparenchymal lesions within lung. So, unless you dropped a lung, I don't think that's a real risk (i.e. punching through a fungus ball).

And, what about a paravertebral, Jason?

-copro

 

[Planktonmd]

Whabout a contraindication to the thoracic epidural noy?

We had to go open anyhoots.

I wanted to put in a thoracic epidural. My attending felt that having aspergillomas was a contraindication to neuraxial because, technically, its an infection. It would be the same as putting a thoracic epidural in someone with walled off tuberculosis granules (gohn complex...is that wtf they are called?).

So, your attending thinks any infection is a contraindication to epidurals?
Would you ask him his opinion about a lung CA patient with ongoing chronic bronchitis needing a thoracotomy? ( very common scenario)
How about a parturient with ruptured membranes and WBC= 15000?

 

[VentdependenT]

I don't think that aspergilloma usually counts as a "systemic" infection, which is often the contraindication, but this patient wasn't febrile with an indication of sepsis, right, which would point to invasive aspergillosis? But, I do hear you about seeding through a "Ghon" complex, but unless it's invasive aspergilloma balls are, by definition, intraparenchymal lesions within lung. So, unless you dropped a lung, I don't think that's a real risk (i.e. punching through a fungus ball).

And, what about a paravertebral, Jason?

-copro

Paravertebral sounds like a hell of a fine idea to me. Never done one. I suppose one could thread a catheter in there as well. Never done that either.

Could just do a bunch of intercostals with ropi and epi too (basically same as a paravertebral). But that ain't gonna last.

The surgeons infused plenty of local in the wound and the patient woke up with minimal pain. Even generated a good cough. I got too slammed to see her on the floors the next day to evaluate her pain.

 

[phlubarb]

You said she was on a bunch of immunomodulators, was she on steroids? I ask because our lung transplant patients don't get thoracic epidurals for single lung transplants b/c they don't have too much postop pain, which we attribute to being on high dose steroids for rejection purposes.

Out.

 

[VentdependenT]

You said she was on a bunch of immunomodulators, was she on steroids? I ask because our lung transplant patients don't get thoracic epidurals for single lung transplants b/c they don't have too much postop pain, which we attribute to being on high dose steroids for rejection purposes.

Out.

She was also on prednisone.

I wasn't aware that steroids mediated the pain response.

 

[dhb]

By inhibiting the inflammatory pathways they'll work in the same way as your NSAID's

 

[VentdependenT]

By inhibiting the inflammatory pathways they'll work in the same way as your NSAID's

Makes sense.

 

[zippy2u]

Let's not have a cow over this case, your classic "dump and run" case... Bang in one-shot 0.5mgs intrathecal duramorph, tell surgeons to throw in 3 level intercostal blocks with 0.5% marcaine with epi and turf to the ICU with an ETT. Prior to transport bang her with 20 ccs of fentanyl IV. Dude, you're in a teaching hospital... got about 10 squirrels(MS-3s to fellows) salivating and trippin' over their own two feet to care for this woman-- transfer the batton and let them be heroes for the day. You really want her to own you for 3 days while ya have that thoracic epidural cath in her back? Regards, ----Zip

 

[Planktonmd]

Let's not have a cow over this case, your classic "dump and run" case... Bang in one-shot 0.5mgs intrathecal duramorph, tell surgeons to throw in 3 level intercostal blocks with 0.5% marcaine with epi and turf to the ICU with an ETT. Prior to transport bang her with 20 ccs of fentanyl IV. Dude, you're in a teaching hospital... got about 10 squirrels(MS-3s to fellows) salivating and trippin' over their own two feet to care for this woman-- transfer the batton and let them be heroes for the day. You really want her to own you for 3 days while ya have that thoracic epidural cath in her back? Regards, ----Zip

Excellent points 😀

 

[VentdependenT]

I titrated in narcs and extubated her on the table.