Very Cool Case

[jetproppilot]

This one takes the cake as far as weird cases I've done.

21 y/o male with aggressive tumor in right lung eek for a complete right lung removal.

Has a liver met....which will be addressed later...

anyway, A line, central line, double lumen tube....

long case with meticulous but good surgeon.

Expected to be able to extubate this dude...hell, if you cant extubate a 21 year old after a lung removal than who can you extubate?

8 hour case.

Breathing on own at end....some high peak pressures on good lung....albuterol down the tube.....

turn him to supine at the end.

Sats 99%....good tidal volumes.....but his color...kinda mottled from about T4 up......

pull the DLT....somethin' aint right....he's maintaining his airway but is tachypneic, nasal flaring....BP 100 systolic...we stay in the OR and get a CXR.....left lung looks great....can't really appreciate the normal heart orders in the left chest..

in the right chest on CXR, where I expected to see just black (lung gone) theres this puffy appearing round area....is it a lap? Scrub tech assures us lap count correct.

Whaddya do now? Reintubate him and go to ICU?

I know for sure he needs intubation, so I do that.

Still that weird blue color in his upper body....legs pink....

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[VentdependenT]

This one takes the cake as far as weird cases I've done.

21 y/o male with aggressive tumor in right lung eek for a complete right lung removal.

Has a liver met....which will be addressed later...

anyway, A line, central line, double lumen tube....

long case with meticulous but good surgeon.

Expected to be able to extubate this dude...hell, if you cant extubate a 21 year old after a lung removal than who can you extubate?

8 hour case.

Breathing on own at end....some high peak pressures on good lung....albuterol down the tube.....

turn him to supine at the end.

Sats 99%....good tidal volumes.....but his color...kinda mottled from about T4 up......

pull the DLT....somethin' aint right....he's maintaining his airway but is tachypneic, nasal flaring....BP 100 systolic...we stay in the OR and get a CXR.....left lung looks great....can't really appreciate the normal heart orders in the left chest..

in the right chest on CXR, where I expected to see just black (lung gone) theres this puffy appearing round area....is it a lap? Scrub tech assures us lap count correct.

Whaddya do now? Reintubate him and go to ICU?

I know for sure he needs intubation, so I do that.

Still that weird blue color in his upper body....legs pink....

Holy christ dude.

This guy herniate his guts into his right chest through the diaphragm? Squishing his heart now?

Tube this somnabitch and get that surgeon back in there to look around.

 

[pd4emergence]

This one takes the cake as far as weird cases I've done.

21 y/o male with aggressive tumor in right lung eek for a complete right lung removal.

Has a liver met....which will be addressed later...

anyway, A line, central line, double lumen tube....

long case with meticulous but good surgeon.

Expected to be able to extubate this dude...hell, if you cant extubate a 21 year old after a lung removal than who can you extubate?

8 hour case.

Breathing on own at end....some high peak pressures on good lung....albuterol down the tube.....

turn him to supine at the end.

Sats 99%....good tidal volumes.....but his color...kinda mottled from about T4 up......

pull the DLT....somethin' aint right....he's maintaining his airway but is tachypneic, nasal flaring....BP 100 systolic...we stay in the OR and get a CXR.....left lung looks great....can't really appreciate the normal heart orders in the left chest..

in the right chest on CXR, where I expected to see just black (lung gone) theres this puffy appearing round area....is it a lap? Scrub tech assures us lap count correct.

Whaddya do now? Reintubate him and go to ICU?

I know for sure he needs intubation, so I do that.

Still that weird blue color in his upper body....legs pink....

Sounds like the mottled skin above maybe an SVC/Venous drainage problem. The fact that he decompensated after extubation makes me wonder if there is something in the chest compressing these structures with the most likely being air or blood. How were his drains/tubes? Definitely, I would get the surgeon to come look at him and the CXR before taking him anywhere.

 

[militarymd]

Mediastinum herniated into r thorax???

TEE..

CT...


if time...

or straight back into chest with surgeon.

 

[militarymd]

Was this it?

 

[Ferdie]

mediastinum herniated into R hemithorax with SVC compression?

 

[UTSouthwestern]

An EIGHT hour pneumonectomy on a 21 year old?

Yes he's herniated into the right thorax with a twisting phenomenon on the great vessels. Hopefully this was an acute process caught early on as that mottling in the upper part of his body likely includes hypoperfusion of the cortex.

Reopen immediately. You already have a CXR with an anomalous mass in the right thorax.

 

[jetproppilot]

Ya'll nailed it!!

Nice job.

Yep....heart herniated into right thorax, twisting the SVC and impairing venous drainage.

Mil, that was a pretty CXR. The portable we got didnt look like that....all that could be seen was.....looked like a collection of cotton balls in a weird shape....but it was in fact the heart.

We never left the room.

Surgeon reopened, and there was the heart....

He basically pushed it back in, untwisting it at same time....

repaired where the breach occurred....

guys color back to normal....

went to ICU intubated but he was extubated the next day...

chest tubes out now....

he's doing well.

 

[cfdavid]

Can you elaborate on the "breach"? Was the entire right lung removed? I'm assuming the mediastinal part of the parietal pleura is left alone, and thus is the traditional (and only) barrier to a herniation in such a case?

 

[VentdependenT]

Ya'll nailed it!!

Nice job.

Yep....heart herniated into right thorax, twisting the SVC and impairing venous drainage.

Mil, that was a pretty CXR. The portable we got didnt look like that....all that could be seen was.....looked like a collection of cotton balls in a weird shape....but it was in fact the heart.

We never left the room.

Surgeon reopened, and there was the heart....

He basically pushed it back in, untwisting it at same time....

repaired where the breach occurred....

guys color back to normal....

went to ICU intubated but he was extubated the next day...

chest tubes out now....

he's doing well.

Sweet case Jet (for us at least)! Thanks for the post.

The skin changes were from back up of venous blood eh? Thats pretty insane my man.

 

[Apollyon]

The skin changes were from back up of venous blood eh? Thats pretty insane my man.

Had a case over the weekend like that - pt with chronic edema, but asserts that the coloration is new. R foot is puffy and red and "sweating" clear fluid. L foot is dusky. Pt is on Coumadin. No pulses in L foot, DP in R, popliteal in both. Interesting thing is that the pt cut her leg, anterior tibia, and it is draining serous fluid with the slightest tinge of pink. It's just dripping like squeezing a sponge.

The serous drainage actually took the edema down nicely, but I have to look up the patient to see what the deal was with the L foot - no pulses and no edema, but dusky/purple and certainly not pale like an arterial occlusion, and no pain. Emergently to the university hospital to have vascular Sx eval and treat.

 

[pd4emergence]

Great case. Thanks for posting. Didn't think of herniation but I seem to learn something new everyday (at least until the alcoholic dementia hits).

 

[Ferdie]

can I just say that I love you guys? y'all make me smarter

 

[toughlife]

One for the "cold case file" indeed!