Postoperative management of iatrogenic membranous tracheobronchial injury following bilateral lung transplant.
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ABSTRACT:
SUBMITTER: Hwalek AE
PROVIDER: S-EPMC8300037 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Acute lung injury following lung resection surgery is not rare and often related to mortality. Although it has been a significant clinical and economic impact associated with increased intensive care unit (ICU) utilization, length of hospital stay, and associated cost, it is unpredictable. Aims of this study were to identify the modifiable risk factors of postoperative acute lung injury (PALI) following lung cancer surgery.We retrospectively analyzed medical records of 354 cases of lung cancer surgery in the tertiary university hospital from January 2012 to December 2015. PALI was defined as bilateral diffuse pulmonary infiltration on chest radiography, oxygenation failure (PaO2/FiO2 < 300), and absence of sign of left ventricular failure within a week from operation. We classified patients into either PALI group or non-PALI group and compared clinical characteristics of two groups. Logistic regression model was fitted to evaluate the risk factor of PALI.Among 354 cases of lung cancer surgeries, 287 lobectomies were analyzed. The overall incidence of PALI was 2.79% (8/287); four patients developed pneumonia with acute respiratory distress syndrome, and four patients developed ALI without clinical infection sign. There was no difference in baseline characteristics between PALI group and non-PALI group, but in operative parameters, a larger amount of fluid infusion was observed in PALI group. Logistic regression model showed underlying ischemic heart disease (OR 7.67, 95% CI 1.21-47.44, P = .03), interstitial lung disease (OR 30.36, 95% CI 2.30-401.52, P = .01), intravascular crystalloid fluid during surgery (OR 1.10, 95% CI 1.00-1.20, P = .04), and intraoperative transfusion (OR 56.4, 95% CI 3.53-901.39, P < .01) were risk factors of PALI. PALI increases ICU admission, use of mechanical ventilator, duration of hospital stay, and mortality.The clinical impact of PALI is marked. Significant independent risk factors have been identified in underlying ischemic heart disease, interstitial lung disease, intravascular crystalloid fluid, and transfusion during surgery.
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Project description:A 64-year-old man with interstitial pulmonary fibrosis and a small patent foramen ovale with right-to-left shunting underwent bilateral lung transplant without closure of the patent foramen ovale. Postoperatively, the patient remained persistently hypoxemic with partial response to high-flow oxygen. Investigations revealed the presence of a large patent foramen ovale with right-to-left shunting on echocardiography and a shunt fraction of 21% on cardiac catheterization. Two months after the lung transplantation, primary surgical repair of the patent foramen ovale was performed with immediate improvement in oxygenation. Three years postoperatively, the patient remained oxygen independent.
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Project description:PurposeRecognize a rare yet existing risk of severe visual loss as a postoperative complication of bilateral lung transplant.ObservationsA 62-year-old male had undergone bilateral lung transplant for end-stage idiopathic pulmonary fibrosis and emphysema overlap syndrome. The operation was initially off-pump; however, during the left lung transplantation, cardiopulmonary bypass conversion was necessary to maintain intraoperative hemodynamic stability. On post-operative day 4, shortly after extubation and full recovery from sedation, the patient reported bilateral no light perception vision. There were no other associated neurologic symptoms. A computed tomographic (CT) of the head, cranial magnetic resonance (MR) scan of the head, MR angiogram of the circle of Willis and neck were negative. Neuro-ophthalmologic examination revealed no light perception vision in both eyes(OU). The pupils were non-reactive to light (amaurotic pupils). The intraocular pressure measured 18 mm Hg OU, and complete bilateral ophthalmoplegia was present. The fundus exam showed bilateral pallid optic disc edema, cherry red spots, with arteriolar attenuation, and mildly dilated and tortuous veins. Stroke work up was negative.Conclusions and importanceA case of post-operative visual loss and ophthalmoplegia carrying significant and permanent quality of life implications. It questions the role disruption of homeostasis during cardiopulmonary bypass contributes for this outcome.
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Project description:Pulmonary Artery banding (PAB) is limited to selected patients who cannot undergo primary repair due to complex anatomy, associated co-morbidities, as a part of staged univentricular palliation, and for preparing the left ventricle prior to an arterial switch operation. We report a catastrophic iatrogenic complication in which the pulmonary artery was injured during the PAB. We discuss its multi-pronged management.
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Project description:RationaleDespite the importance of bronchiolitis obliterans syndrome (BOS) in lung transplantation, little is known regarding the factors that influence survival after the onset of this condition, particularly among bilateral transplant recipients.ObjectivesTo identify factors that influence survival after the onset of BOS among bilateral lung transplant recipients.MethodsThe effect of demographic or clinical factors, occurring before BOS, upon survival after the onset of BOS was studied in 95 bilateral lung transplant recipient using Cox proportional hazards models.Measurements and main resultsAlthough many factors, including prior acute rejection or rejection treatments, were not associated with survival after BOS, BOS onset within 2 years of transplantation (early-onset BOS), or BOS onset grade of 2 or 3 (high-grade onset) were predictive of significantly worse survival (early onset P = 0.04; hazard ratio, 1.84; 95% confidence interval, 1.03-3.29; high-grade onset P = 0.003; hazard ratio, 2.40; 95% confidence interval, 1.34-4.32). The effects of both early onset and high-grade onset on survival persisted in multivariable analysis and after adjustment for concurrent treatments. Results suggested an interaction might exist between early onset and high-grade onset. In particular, high-grade onset of BOS, regardless of its timing after transplant, is associated with a very poor prognosis.ConclusionsThe course of BOS after bilateral lung transplantation is variable. Distinct patterns of survival after BOS are evident and related to timing or severity of onset. Further characterization of these subgroups should provide a more rational basis from which to design, stratify, and assess response in future BOS treatment trials.
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Project description:The subclavian artery at the thoracic outlet is in the deepest position of the thoracic cavity and is difficult to repair in this narrow space once injured, even if the surgery is converted to a thoracotomy. This article presents a successful left subclavian artery repair procedure at the thoracic outlet using a thoracoscopic approach, with a video demonstration, and describes its technical characteristics. The patient was planned for a left upper lobectomy through three-port thoracoscopic approach. Severe adhesions were found intraoperatively and an accidental left subclavian arterial injury occurred when dissecting the adhesions. We first clamped the proximal portion of the subclavian artery and then directly clamped the rupture site. Our first suture failed due to the limited suture angle and the mutual restriction between the needle holder and atraumatic vascular clamp. To freely control the needle holder, another assistant port was made in the seventh intercostal space (ICS). The arterial injury was finally successfully repaired using pledgetted suture. The operation time was 235 minutes and intraoperative blood loss was 800 mL. The pulsation of the left radial artery was normal postoperatively, and the patient was discharged on postoperative day 6. Appropriate strategies allow attempts to manage intraoperative hyperbaric arterial bleeding from the systemic circulation, such as bleeding caused by subclavian arterial injuries, by means of a thoracoscopic approach without conversion to thoracotomy.
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Project description:IntroductionSimultaneous bilateral total knee arthroplasty (bTKA) is a viable option for treatment of bilateral knee osteoarthritis. The aim of this study is to identify the impact of biological sex on postoperative outcomes.MethodsA retrospective cohort study was conducted utilizing the ACS-NSQIP database. bTKA patients were identified and stratified into groups based upon biological sex. Adverse events after surgery was evaluated with univariate and multivariate analysis.ResultsBiological sex is not an independent risk factor for development of postoperative complications.ConclusionWhen determining patient qualification of simultaneous or staged bTKA, biological sex should not be taken into consideration.
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Project description:BackgroundSelective dorsal rhizotomy (SDR) is a neurosurgical procedure that reduces lower limb spasticity, performed in some children with spastic diplegic cerebral palsy. Effective pain management after SDR is essential for early rehabilitation. This study aimed to describe the anaesthetic and early pain management, pain and adverse events in children following SDR.MethodsThis was a retrospective cohort study. Participants were all children who underwent SDR at a single Australian tertiary hospital between 2010 and 2020. Electronic medical records of all children identified were reviewed. Data collected included demographic and clinical data (pain scores, key clinical outcomes, adverse events and side effects) and medications used during anaesthesia and postoperative recovery.Results22 children (n=8, 36% female) had SDR. The mean (SD) age at surgery was 6 years and 6 months (1 year and 4 months). Common intraoperative medications used were remifentanil (100%), ketamine (95%), paracetamol (91%) and sevoflurane (86%). Postoperatively, all children were prescribed opioid nurse-controlled analgesia (morphine, 36%; fentanyl, 36%; and oxycodone, 18%) and concomitant ketamine infusion. Opioid doses were maximal on the day after surgery. The mean (SD) daily average pain score (Wong-Baker FACES scale) on the day after surgery was 1.4 (0.9), decreasing to 1.0 (0.5) on postoperative day 6 (POD6). Children first attended the physiotherapy gym on median day 7 (POD8, range 7-8). Most children experienced mild side effects or adverse events that were managed conservatively. Common side effects included constipation (n=19), nausea and vomiting (n=18), and pruritus (n=14). No patient required return to theatre, ICU admission or prolonged inpatient stay.ConclusionsMost children achieve good pain management following SDR with opioid and ketamine infusions. Adverse events, while common, are typically mild and managed with medication or therapy. This information can be used as a baseline to improve postoperative care and to support families' understanding of SDR before surgery.
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Project description:Chronic lung disease has been attributed to stem cell aging and/or exhaustion. We investigated these mechanisms using mouse and human tracheobronchial tissue-specific stem cells (TSC). In mouse, chromatin labeling and flow cytometry demonstrated that naphthalene (NA) injury activated a subset of TSC. These activated TSC continued to proliferate after the epithelium was repaired and a clone study demonstrated that ~96% of activated TSC underwent terminal differentiation. Despite TSC attrition, epithelial repair after a second NA injury was normal. The second injury accelerated proliferation of previously activated TSC and a nucleotide-label retention study indicated that the second injury recruited TSC that were quiescent during the first injury. These mouse studies indicate that (a) injury causes selective activation of the TSC pool; (b) activated TSC are predisposed to further proliferation; and (c) the activated state leads to terminal differentiation. In human TSC, repeated proliferation also led to terminal differentiation and depleted the TSC pool. A clone study identified long- and short-lived TSC and showed that short-lived TSC clones had significantly shorter telomeres than their long-lived counterparts. The TSC pool was significantly depleted in dyskeratosis congenita donors, who harbor mutations in telomere biology genes. The remaining TSC had short telomeres and short lifespans. Collectively, the mouse and human studies support a model in which epithelial injury increases the biological age of the responding TSC. When applied to chronic lung disease, this model suggests that repeated injury accelerates the biological aging process resulting in abnormal repair and disease initiation.
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