1. Pneumonectomy After Trauma and Complex Airway Management in the Critical Care Setting
Andrew G. Cook MD, Roman Dudaryk MD, Jack Louro MD
Department of Anesthesiology, Perioperative Medicine and Pain Management University of Miami / Jackson Health System Miami, Florida
Patient History
21 year old male with no past medical history presented to the trauma center with a gunshot wound to the right axilla, passing through the right pulmonary hilum, and eventually resting in the vertebral column.
Airway Imaging
Airway Management
Left sided double lumen tube used to isolate left lung and allow the right bronchial stump to heal.
Repeated difficulty of keeping double lumen tube patent.
Use of VV-ECMO as a novel method to maintain oxygenation while safely performing a tracheostomy in a critically ill patient with bronchial leak
Reinforced tracheal tube through a modified tracheostomy cannula
Figure 2: Chest Xray showing reinforced endotrachial tube through a tracheostomy (POD 85)
Figure 3: CT scan showing reinforced endotrachial tube through a tracheostomy (POD 85) n
Postoperative Course and Events
Patient presented to our satellite trauma center and underwent emergent bilateral thoracotomy with right sided pneumonectomy. He subsequently developed abdominal compartment syndrome requiring exploratory laparotomy and decompression with open chest and abdomen. The patient had poor oxygenation and was immediately started on AV-ECMO. He was then transferred to our main trauma facility. ECMO was complicated by thrombosis of the right femoral artery with attempted repair that progressed to right leg ischemia at the initial cannulation site requiring a right sided below knee amputation. He was switched to VV-ECMO with the outflow cannula in the right pulmonary artery stump. Due to a bronchopleural fistula at the pneumonectomy stump site, the patient was managed with a left sided double lumen tube. Patient experienced multiple pneumonias and blockages of the double lumen tube. Therefore, patient was placed on VV-ECMO just prior to tracheostomy placement with a modified inner cannula inserted into the left mainstem bronchus.
Discussion
ECMO use in trauma patients traditionally limited due to need for heparinization
Right sided pneumonectomy has been shown to have a greater incidence of bronchopleural fistula.
Double lumen tubes are the preferred method for prolonged periods of lung separation in the intensive care unit
No long term studies that detail complication rates such as bronchomalacia from prolonged mainstem intubation.
Latest generation of ECMO devices allowing for greater use in trauma
Extra Corporeal Membrane Oxygenation
POD 0: AV-ECMO via right femoral arterial Medtronic 21-French percutaneous cannula and left femoral venous 25-French percutaneous venous cannula
POD 22: VV-ECMO with a 23- French double lumen Avalon cannula via the right internal jugular into the proximal inferior vena cava under fluoroscopy
POD 27: ECMO Decannulation
POD 53: VV-ECMO with a 19-French venous line in the left femoral artery and 19-French arterial cannula in the right internal jugular vein advanced towards the superior vena cava.
POD 55: Tracheostomy with a 10-French tracheostomy tube then intubated into the left mainstem bronchus with a reinforced 6.0 ETT via the tracheostomy
POD 61: ECMO Decannulation dc
Figure 1: Initial chest Xray s/p pneumonectomy showing lung injury and bullet fragments (POD 1)
References
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