Complication following resection of lung
â˘Download as PPTX, PDFâ˘
0 likesâ˘49 views
..............
Recommended
More Related Content
What's hot
What's hot (20)
Similar to Complication following resection of lung
Similar to Complication following resection of lung (20)
More from EWOPCRE
Recently uploaded
Recently uploaded (20)
Complication following resection of lung
- 1. COMPLICATIONS FOLLOWING THORACIC SURGERY Dr. Ashok Pradhan 2nd Year Mch MCVTC
- 2. Respiratory Complications Atelectasis and Pneumonia 1. Inadequate Pain Control 2. Respiratory paralysis 3. Diaphragmatic paralysis
- 3. ⢠Thoracotomy -most painful of surgical procedures ⢠Ineffective pain relief ďImpeds deep breathing, coughing, and mobilization
- 4. Pathophysiology of pain ⢠In response to tissue injury, inflammatory mediators, are released ⢠Activate nociceptors ďźSomatic and visceral afferent ⢠Leads to intensified pain on breathing or coughing after operation
- 5. Pathophysiology of pain ⢠In response to tissue injury, inflammatory mediators, are released ⢠Activate nociceptors ďźSomatic and visceral afferent ⢠Leads to intensified pain on breathing or coughing after operation
- 6. â˘Transmitted to the somatosensory cortices via the contralateral anterolateral system of the spinal cord â˘Neuropathic pain, after intercostal nerve injury, develops with hypersensitivity (allodynia, hyperalgesia, and hyperpathia)
- 7. Surgical factors â˘Posterolateral approach Involves dividing the latissimus dorsi, and at times the serratus anterior and trapezius muscles â˘Alternative muscle-sparing approaches â˘Excessive rib retraction fracture, dislocation, costovertebral disruption, and damage to the intercostal nerves
- 8. Patient factors ⢠Young, female gender, history of depression and anxiety HYV Abrishami A Peng PWH Wong J Chung F Predictors of postoperative pain and analgesic consumption Anesthesiology 2009
- 10. Regional anaesthesia ⢠Thoracic epidural analgesia ⢠Combined local anaesthetic/opioid epidural solution ⢠0.1â0.125% bupivacaine + 2â5 Âľg ml fentanyl at 0.1 ml /kg/ h Ref: Shelley B, Macfie A, Kinsella J. Anesthesia for thoracic surgery: a survey of UK practice. J Cardiothorac Vasc Anesth 2011; 25: 1014â7
- 12. Paravertebral analgesia ⢠Paravertebral space is a potential space ⢠Lateral to the vertebral column ⢠posterior to the parietal pleura and anterior to the costotransverse ligament
- 15. Prolonged air leak ⢠Communication between the pulmonary parenchyma distal to a segmental bronchus and the pleural space â˘Affecting up to 25% of patients undergoing pulmonary resection ⢠More than six- seven days after lung resection
- 16. Cont.
- 17. Intra-operative management â˘Muscle sparing thoracotomy â˘Stapler to divide the fissures. â˘Bronchus division by stapler (Ethicon) unless there is a close resection margin
- 18. â˘Cost analysis of pulmonary lobectomy procedure: comparison of stapler versus precision dissection and sealant Andrea Droghetti, Giuseppe Marulli, Jacopo Vannucci, Michele Giovanardi, Maria Caterina Bottoli, Mark Ragusa,Giovanni Muriana Conclusion : significantly reduce incidence and duration air leakage , as well as decrease hospitalization rates
- 19. ⢠Brunelli A, Monteverde M, Borri A et al.Predictors of prolonged air leak after pulmonary lobectomy. Ann Thorac Surg 2004; ďśfound an 8.2% to 10.4% rate of empyema in patients with air leak lasting more than 7 days versus a rate of only 0% to 1.1% in patients with lesser air leaks. ⢠Varela G, JimĂŠnez MF, Novoa N, Aranda JL. Estimating hospital costs attributable to prolonged air leak in pulmonary lobectomy. Eur J Cardiothorac Surg 2005 ďśVarela found that air leak lasting at least five days was associated with greater pulmonary morbidity including atelectasis, pneumonia or empyema
- 20. Three major factors â˘Volume â˘Duration, and â˘Trend of the leak
- 21. â˘Positive-pressure ventilation- daily spontaneous breathing trials â˘Keeping under negative suction Cerfolio R.J., Bass C., Katholi C.R. Prospective randomized trial compares suction versus water seal for air leaks. Ann Thorac Surg. 2001;71(5):1613â1617 â˘If fails to resolve the air leak Heimlich valve
- 22. Cerfolio et al showed the safety of chest tube removal if a PAL remained after the patient was discharged home with a Heimlich valve, as long as the patient was asymptomatic without subcutaneous emphysema and the pneumothorax had not increased in size [PubMed] [Google Scholar]
- 23. Chemical Pleurodesis Common sclerosing agents include ⢠Talc ⢠Doxycycline ⢠Tetracycline ⢠Minocycline ⢠Bleomycin Liberman et al,40 of 41 patients with a PAL postlobectomy were successfully treated with talc pleurodesis. How C., Tsai T., Kuo S. Chemical pleurodesis for prolonged postoperative air leak in primary spontaneous pneumthorax
- 24. Autologous Blood Patch Pleurodesis â˘Autologous blood patch pleurodesis was first used by Robinsonin 1987 for the treatment of PALs Lang-Lazdunski L., Coonar A.S. A prospective study of autologous âblood patchâ Pleurodesis for persistent air leak after pulmonary resection
- 25. Endobronchial/Intrabronchial Valves ⢠Mahajan A.K., Doeing D.C., Hogarth D.K. Isolation of persistent air leaks and placement of intrabronchial valves. J Thorac Cardiovasc Surg. 2013;145(3):626â 630. [PMC free article] [PubMed] [Google Scholar] ⢠Kovtiz K.L., French K.D. Endobronchial valve placement and balloon occlusion for persistent air leak. Chest. 2013;144(2):661â665. [PubMed] [Google Scholar] ⢠Mahajan A.K., Verhoef P., Patel S.B. Intrabronchial valves: a case series describing a minimally invasive approach to bronchopleural fistulas in medical intensive care unit patients. J Bronchology Interv Pulmonol. 2012;19(2):137â 141. [PMC free article] [PubMed] [Google Scholar]
- 27. ADULT RESPIRATORY DISTRESS SYNDROME ⢠Sepsis ⢠Capillary damage ⢠Exudation of inflammatory cells and protein rich fluid into interstitium Alveoli destruction (type I cell and type II cell)ď atelectasis and collapse ⢠Damaged protein, necrotic cells and oedema leads to Hyaline membrane formation ⢠Physiological shunting ď V/Q mismatch ď Hypoxia ď Respiratory failure
- 28. Diagnosis ⢠Acute onset ⢠Diffuse bilateral pulmonary infiltrate on x-ray chest ⢠Pa02 / FI02 < 200 mm Hg ⢠Absence of elevated left atrial pressure
- 31. ⢠Ventilator support ⢠TV 6-8ML/KG ⢠Pa02 >65mmHg ⢠Diuresis ⢠Steroids ⢠NO ⢠ECMO
- 34. Atrial fibrillation ⢠Onset of AF - postoperative days 2 and 3 ⢠10% to 20% after pulmonary lobectomy ⢠30-40% after pneumonectomy
- 35. Etiology and Risk Factors ⢠Male sex ⢠Increasing age ⢠History of congestive heart failure ⢠Preoperative episodes of AF ⢠Procedures associated with pericardial inflammation, especially dissection around the atria
- 38. Myocardial Infarction â˘5- 10% â˘K/C/O CAD Classified as â˘NSTEMI â˘STEMI
- 41. Postoperative hemorrhage 0.06% Causes Injury to pulmonary artery Inferior pulmonary ligament Dissected LN, station 5 Chest tube site
- 42. Cont.. ⢠Monitored by chest tube drinage ⢠Large sanguineous volume Immediate re-exploration Platelet dysfunction/ Antiplatelet therapy/Anticoagulant therapy Prothrombin complex/ PRP
- 44. Bronchopleural fistula ⢠Direct communication B/W lobar or segmental bronchus and pleural space ⢠8.6% in rt pneumonectomy & 2.6% in left pneumonectomy ⢠1% after lobectomy ⢠0.3% after segmentectomy
- 46. Risk factors Patient factor â˘Infectious etiology â˘Preoperative irradiation â˘RT pneumonectomy â˘DM â˘Malnourished Surgeonâs factor â˘Long stump â˘Injury to the artery supplying the bronchus â˘Leaving LN/ tumor on the bronchus â˘Intraoperative blood loss and ionotropic support
- 47. Clinical features ⢠Fever ⢠Productive cough with pleural fluid ⢠Continous air leak ⢠Purulent fluid in water seal drainage ⢠Aspiration- pneumonia
- 52. â˘Bronchoscopy â˘examine the stump and to identify the area of leak. â˘If the hole cannot be visualized, â˘slow administration of saline via the bronchoscope into the stump â˘If the stump is not the area of leak, â˘occlusion with balloon tipped catheter
- 53. Treatment Endobronchial closure ⢠biological glues, adhesives, stents, vascular plugs, and coils Operative closure ⢠leaking bronchial stump
- 54. Cont ⢠Trimming a long bronchial stump ⢠Debriding a poorly vascularized stump
- 55. â˘If vascularized tissue is inadequate to close a bronchopleural fistula Extraskeletal muscle is sewn circumferentially to the stump â˘Persistent pleural space after lung resection Pleural tent
- 56. ⢠Filling of a residual space with healthy living tissue such as muscle or omentum ⢠Thoracoplasty
- 57. Bronchovascular Fistula ⢠Rare complication ⢠Massive bleed, followed by massive hemoptysis. ⢠Decrease the chance of fistula formation by placing vascularized tissue â˘Intercostal or extraskeletal muscle, pleura, pericardium, or omentum
- 58. Postpneumonectomy syndrome ⢠Syndrome of dynamic airway obstruction ⢠Extreme rotation and Shift of the mediastinum ⢠Central airway compression
- 60. â˘Common After right-sided pneumonectomy â˘Common in children ⢠Increased elasticity and compliance of the lung and mediastinal tissue
- 61. â˘In the case of a right pneumonectomy â˘Counterclockwise rotation of the heart and great vessels â˘Mediastinum shifts to the right and posteriorly â˘Main bronchus becomes compressed between the left pulmonary artery and vertebral column or descending aorta
- 62. In the case of a left pneumonectomy Mediastinum rotates clockwise. Mediastinal shift and rotation are accompanied by herniation and hyperinflation of the remaining lung Bronchus compressed between the right pulmonary artery and vertebral column
- 63. Clinical features ⢠Progressive dyspnea ⢠Stridor ⢠Respiratory failure or ⢠Tracheomalacia
- 66. ⢠Division of the ligamentum arteriosum, fixation of the aorta or pulmonary artery to the sternum ⢠Suture fixation of the pericardium to the back of the sternum ⢠Placement of prostheses to fill the empty hemithorax
- 67. Prevention ⢠Postoperative installation of air into cavity ⢠Clamping the tube for 1 hour and releasing to see if any bleed present or not for 5 minutes and continuing it
- 68. Empyema ⢠Rare ⢠Open to allow adequate drainage. ⢠If cause of empyema is a bronchopleural fistula ⢠definitive treatment
- 69. Post-thoracotomy Pain ⢠Devastating and debilitating result after thoracotomy ⢠Occurs along thoracotomy scar at least 2 months after surgery ⢠Incidence is 44% to 67%
- 70. Cont â˘Treatment can involve several modalities, including medication and procedures â˘Combinations of medication â˘Nonsteroidal anti-inflammatory drugs, â˘Tricyclic antidepressants, â˘Gabapentin, â˘Opioids and â˘Lidocaine patches
- 71. Procedural treatments ⢠Intercostal nerve block ⢠Paravertebral block, ⢠Intrapleural local anesthetic ⢠Radiofrequency ablation ⢠Cryoablation and ⢠Transcutaneous electrical nerve stimulation
- 72. Chylothorax ⢠0.4% to 0.8% ⢠Manifests several days after the operation ⢠Tube feeding or oral intake is started
- 73. ⢠Dissection around tracheobronchial
- 74. ⢠Milky whitish fluid from the chest tube is diagnostic ⢠Analysis of the fluid for lipids â˘Triglyceride-to-cholesterol ratio of greater than 1 â˘Triglyceride level greater than 110 g/dl
- 75. Conservative measures ⢠Only LN biopsy from area bw hilum and diaphragm-(0n rt LN area) can be damaged or its tributaries can damaged. If low volume chylomicrone then conservative managemant ⢠low-fat or medium-chain triglyceride diet can be tried ⢠NPO status and total parenteral nutrition ⢠If surgery is with in oesophagus no conservative management ⢠Octreotide infusion or subcutaneous administration
- 76. Indication for surgery or ligation ⢠Surgery around the oesophagus
- 77. Procedure ⢠Percutaneous embolization of the thoracic duct or cisterna chyli ⢠Thoracic duct ligation just above the right hemidiaphragm ⢠Thoracoscopically ⢠Thoracotomy ⢠Chest tube output should decrease drastically ⢠Ecourage feeding
- 78. ⢠Mass ligation ⢠Relationship bw chyle and thoracic duct ⢠Relationship bw direction of rt side thoracic duct and left thoracic duct ⢠Why not on left side it get injure ⢠Just behind the subclavian atery on left and above t4/5 or hilum so not injured during resection but around lt subclavian artery it might get injure.
Editor's Notes
- is a complete or partial collapse of the entire lung or area (lobe) of the lung. It occurs when the tiny air sacs (alveoli) within the lung become deflated or possibly filled with alveolar fluid. Atelectasis is one of the most common breathing (respiratory) complications after surgery.
- Somatic afferents are conveyed by the intercostal nerves after skin incision, rib retraction, muscle splitting, injury to the parietal pleura, and chest drain insertion to the ipsilateral dorsal horn of the spinal cord (T4âT10) visceral afferents are conveyed by the phrenic and vagus nerves after injury to the bronchi, visceral pleura, and pericardium
- Somatic afferents are conveyed by the intercostal nerves after skin incision, rib retraction, muscle splitting, injury to the parietal pleura, and chest drain insertion to the ipsilateral dorsal horn of the spinal cord (T4âT10) visceral afferents are conveyed by the phrenic and vagus nerves after injury to the bronchi, visceral pleura, and pericardium
- Hyperpathia- An increased sensitivity to feeling pain and an extreme response to pain. Hyperalgesia  painful sensation in response to a normally innocuous stimulus allodynia Activities that aren't usually painful (like combing one's hair) can cause severe pain
- cision of the muscles is replaced with dissection and reflection onto the ribs
- Insertion of a thoracic epidural before general anaesthesia facilitates patient feedback on improper placement and permits the assessment of its efficacy. The insertion point is usually midway along the dermatomal distribution of the thoracotomy incision at the level of T5âT6. Difficulty in locating the epidural space is often encountered due to the steep caudal angulation of the spinous processes at this level; therefore, some anaesthetists prefer a
- Insertion of paramedian thoracic epidural. The needle is inserted 1 cm lateral to the superior tip of the spinous process and then advanced perpendicular to all planes to contact the lamina of the vertebral body immediately below. The needle is âwalkedâ up the lamina at an angle rostrally (45°) and medially (20°) until the rostral edge of the lamina is felt. The needle is advanced over the edge of the lamina, seeking a loss of resistance on entering the epidural space after transversing the ligamentum flavum. The laminar approach (B) is favoured by other practitioners. The needle is inserted next to the rostral edge of the spinous process and advanced straight without any angle from the midline
- Bronchial stump and lung parenchyma - tested against 25cm water pressure using positive ventilation via hand bagging If the bronchial stump was the cause, it was re-sutured and retested until no air leak was present. If the culprit was from the lung parenchyma- Rx according to surgeonâs preference Mild air leaks (with a ventilatory loss of <500ml/min of air) were treated conservatively while for moderate or severe air leaks the source was sought
- the patient is receiving positive-pressure ventilation, reducing the inspiratory time, end-expiratory pressure, and tidal volume can help diminish the air leak WhileHenry Heimlich developed a one-way tube in the 1960s in which air and fluid are only able to flow one way, from the pleural space to outside the chest wall.Â
- Sclerosants are chemicals that cause an inflammatory response and, when administered into the pleural space, allow for sealing of the pleural space, cessation of an air leak, and prevention of recurrent pneumothorax.
- Typically, 50 to 100Â mL of peripheral venous blood is taken from the patientâs arm and injected under sterile conditions through the chest tube into the pleural cavity.42Â The chest tube is then flushed with 10Â mL of normal saline and either clamped or hooked over a drip stand so that air can escape, reducing the risk of tension physiology developing while allowing the blood to remain in the pleural space.42Â Reported complications are rare but include tension pneumothorax secondary to an obstructing clot in the chest tube, pleuritis, and empyema (incidence reported 0%-9%).
- are one-way valves placed with a flexible bronchoscope in segmental or subsegmental bronchi to limit airflow to portions of the lungs distal to the placed valve while allowing mucous and air movement in the proximal direction. hese steps include âair leak isolation, airway sizing, and valve deployment.â45 Leak isolation is achieved by sequential balloon occlusion of segmental airways, moving proximally to distally, starting at the mainstem bronchi. The IBV system comes with an airway sizing kit that calibrates the balloon catheter to measure the airway and determine the valve size. Once the valve is placed, the air leak chamber should be observed for four to five ventilatory cycles to assess any change in the degree of the air leak
- decreased arterial PaO2/FiO2 ratio mild ARDS: 201-300 mmHg (â¤39.9 kPa) moderate ARDS: 101-200 mmHg (â¤26.6 kPa) severe ARDS: â¤100 mmHg (â¤13.3 kPa)
- decreased arterial PaO2/FiO2 ratio mild ARDS: 201-300 mmHg (â¤39.9 kPa) moderate ARDS: 101-200 mmHg (â¤26.6 kPa) severe ARDS: â¤100 mmHg (â¤13.3 kPa) e diffuse bilateral coalescent opacities (the only radiological criterion defined by the Consensus Conference).
- right pneumonectomy stump has minimal mediastinal coverage of the bronchial stump compared with a left-sided stump, Finally, the vascular supply to the left mainstem bronchus is augmented by direct vascular branches as the bronchus passes behind the aorta. The blood supply on the right travels from the trachea via local branches in the subcarinal space, which are often disrupted by dissection and lymph node removal.
- Decreasing in the level of airfluid level indicates BPF
- apical portion of the parietal pleura is dissected from the chest wall and tacked to a lower intercostal muscle. The pleura adhere to the surface of the remaining lung and help seal over any leaking areas, and they decrease the volume of space that the remaining lung needs to fill. Either the space on top of the pleural tent in the apex fills with serous fluid, as it does after a pneumonectomy, or the lung expands to fill the whole space. This change is also aided by elevation of the hemidiaphragm. Injection of the phrenic nerve with local anesthetic causes a temporary paralysis that also encourage the hemidiaphragm to rise
- Thoracoplasty is a surgical procedure that was originally designed to permanently collapse the cavities It involved resection of multiple ribs, allowed the apposition of parietal to the visceral or mediastinal pleura. with ribs rection it will decrease th space.
- If massive hemoptysis occurs, an attempt at placing a double-lumen tube to isolate the nonaffected lung from blood spillage may allow enough time for the chest to be opened and the bleeding controlled if DLT not available single lumen tube can be inserted easier in rt bronchus, as it is short vertical and wider left bronchus technically difficult so need bronchoscope diaphragm can be used most vascularised pedicle can be taken and closure of diaphragm and taken tissue can close the stump
- Tracheomalacia is the collapse of the airway when breathing. This means that when your child exhales, the trachea narrows or collapses so much that it may feel hard to breathe. This may lead to a vibrating noise or cough.
- The thoracic duct typically starts at the second lumbar vertebra at the cisterna chyli, ending at the junction of the left subclavian and jugular veins. A total of 1.5 to 2 liters of lymph flows through the thoracic duct per day.[2][3]Â Any leak from this system results in significant morbidity with loss of lymph and secondarily causing respiratory distress. Go to: Surgical causes: Iatrogenic injury while performing procedures on the esophagus, aorta, pleura, lung, vagotomy, spine surgery, and others. One of the leading reasons for the damage of the thoracic duct during surgical interventions is its anatomical variation.[1][4]Â A variation is seen in almost one-third of the population.[5]
- Chyle contains abundant proteins, and patient can become nutritionally depleted quickly It is used in the treatment of chylothorax, because it acts directly on vascular somatostatin receptors to minimize lymphatic fluid excretion. In addition, octreotide increases splanchnic arteriolar resistance and decreases gastrointestinal blood flow, indirectly reducing lymphatic flow.8
- Surgery is recommended if chyle drainage persists for more than 3 weeks, if the daily fluid loss exceeds 1.5 L, or if there is imminent nutritional complication in debilitated patients. ligated between the 8th and 12th vertebrae