Document Detail


Managing the pneumonectomy space after extrapleural pneumonectomy: postoperative intrathoracic pressure monitoring.
MedLine Citation:
PMID:  20056433     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
OBJECTIVE: Rapid fluid evacuation of the pneumonectomy space can cause ipsilateral mediastinal shift, contralateral lung hyperexpansion, compromised caval blood return and a precipitous drop in cardiac output. Conversely, rapid fluid accumulation can cause contralateral mediastinal shift with compression of the remaining lung and respiratory insufficiency. In this retrospective analysis, we evaluate the efficacy of intrathoracic pressure monitoring and intermittent fluid aspiration to manage the pneumonectomy space in the early postoperative period following extrapleural pneumonectomy.
METHODS: Prior to chest closure, a 14 F Rob-Nel catheter was placed in the pneumonectomy space and connected to pressure tubing to monitor ipsilateral intrathoracic pressure continuously. Central venous pressure monitoring and serial chest X-rays were performed according to usual intensive care routine. Pneumonectomy space fluid was aspirated intermittently when there was increase in intrathoracic pressure, refractory hypotension, mediastinal shift on chest X-ray, or clinical decline. Postoperative imaging was re-evaluated retrospectively for confirmation of mediastinal shift by a senior radiologist.
RESULTS: From January to December 2008, 47 patients underwent extrapleural pneumonectomy for pleural mesothelioma (median age 65 years with range 34-79 years, 77% male). Twenty (43%) patients had left-sided disease and 32 (68%) received local heated intra-operative cisplatin-based chemotherapy. The median baseline pneumonectomy space pressure was 3 cm H(2)O (range: -6 to +12). The median amount of fluid withdrawn over the first 2 days postoperatively was 300 cc (range: 0-1980 cc). Thirty-one (69%) patients had minimal, if any, change in mediastinal position during the first 2 postoperative days with intermittent drainage performed when the pneumonectomy space pressure rose. Eleven (25%) patients had increasing contralateral shift, four of whom had return of the mediastinum to baseline during this time period. The median fluid drained from the four patients whose contralateral shift resolved was 290 cc (range: 220-800 cc) compared to 200 cc (range: 150-480 cc) from the seven patients whose contralateral shift remained, but this difference did not reach significance (p=0.365).
CONCLUSIONS: Intrathoracic pressure monitoring may be used as a guide for intermittent fluid evacuation of the pneumonectomy space prior to onset of clinical signs or symptoms, to avoid the cardiopulmonary risks of rapid fluid removal. Contralateral mediastinal shift should be treated with incremental drainage when there is a rise in intrathoracic pressure to prevent cardiovascular complications.
Authors:
Andrea S Wolf; Francine L Jacobson; Tamara R Tilleman; Yolonda Colson; William G Richards; David J Sugarbaker
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Publication Detail:
Type:  Evaluation Studies; Journal Article; Research Support, Non-U.S. Gov't     Date:  2010-01-06
Journal Detail:
Title:  European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery     Volume:  37     ISSN:  1873-734X     ISO Abbreviation:  Eur J Cardiothorac Surg     Publication Date:  2010 Apr 
Date Detail:
Created Date:  2010-03-23     Completed Date:  2011-01-20     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  8804069     Medline TA:  Eur J Cardiothorac Surg     Country:  Germany    
Other Details:
Languages:  eng     Pagination:  770-5     Citation Subset:  IM    
Copyright Information:
Copyright (c) 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
Affiliation:
Division of Thoracic Surgery and Department of Radiology, Brigham and Women's Hospital, Boston, MA 02215, USA. awolf2@partners.org
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MeSH Terms
Descriptor/Qualifier:
Adult
Aged
Antineoplastic Agents / therapeutic use
Central Venous Pressure
Chemotherapy, Adjuvant
Cisplatin / therapeutic use
Female
Humans
Male
Mesothelioma / drug therapy,  surgery*
Middle Aged
Monitoring, Physiologic / methods
Pleural Neoplasms / drug therapy,  surgery*
Pneumonectomy / adverse effects*
Postoperative Care / methods
Retrospective Studies
Suction
Chemical
Reg. No./Substance:
0/Antineoplastic Agents; 15663-27-1/Cisplatin

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine


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