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<P>Karim - I assume he didn't have any other injuries and that it was the penetrating injury through the right lung & hilar vessels which were catastrophic and were the sole cause of his haemorrhage?</P>
<P>Ken - How do you keep the lung twisted as part of DCS? I have seen it done if clamping the hilar vessels fails, but only as an inter-procedure temporising measure prior to pneumonectomy during that initial procedure. I would be interested to know how you prevent the lung "unravelling on itself" for the 8-12 hours prior to going back to theatre. What you say though makes complete sense - arresting the haemorrhage whilst at the same time attempting to limit the massive cytokine cascade (which will undoubtedly kill him if the haemorrhage doesn't.)</P>
<P>Tim - Exactly. Pneumonectomy will reduce his respiratoy physiological reserve by 50% but this will not kill him (pneumonectomies are done all the time for malignant disease etc.) but the shunts and fluid shifts, as you quite rightly say, will. The proliferated cytokine response, SIRS, ARDS and release of leukotrienes from mast cells causing vasoconstriction of the airways (??the cause of his transient dip in oxygen saturation described by Karim) will all exacerbate his problems - all having the potential to cause fulminant pulmonary oedema leading to enormous right-sided cardiac strain. Positive pressure will indeed provide the counter resistance to the pulmonary oedema and will no doubt decompensate when the positive pressure is removed (as in extubation.) The potential for alveolar leakage & heamorrhage will indeed be high and third space fluid will rapidly increase, thereby drowning his airways. This is compounded by the fact that he only had 1 remaining lung (rather than the 2 that his body was used to physiologically) so the pressure through the pulmonary circulation will have rapidly increased, thereby causing a greater pulmonary capillary hydrostatic pressure driving yet more fluid into the pulmonary interstitium.</P>
<P>We had a couple of patients when I did cardiothoracics with the same symptoms post-op pneumonectomy (albeit for malignant disease rather than trauma.) One had an early bronchial stump dehiscence - I guess that this was not the case here? The other had been extubated immediately post operatively and improved significantly with a 1-2 week course of CPAP - this fits in with what Tim says and the protective positive airways pressure influence (he was a young fit man who rapidly decompensated acutely.)</P>
<P>I feel that it was too early in his post-op recovery for a PE to have been the cause of the problem & I doubt that fast AF was the cause either (I have always tended to have seen this after 48-96 hours post-op in cardiothoracic patients.) These patients are frequently intubated for 48/72 hours on the ITU - so perhaps longer might have helped him - although, as has been said, the prognosis due to the inflammatory cascade and physiological insult post-op is very poor in this patient population.</P>
<P>What about using the Novalung (in the same vein as the membrane oxygenation that Ken suggests?) Anyone have any experience of using it with either good/bad results?</P>
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<P>Matthew</P><BR>
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