Postoperative Acute Pulmonary Embolism Following Pulmonary Resections

Postoperative acute pulmonary embolism after pulmonary resections is highly fatal complication. Many literatures have documented cancer to be the highest risk factor for acute pulmonary embolism after pulmonary resections. Early diagnosis of acute pulmonary embolism is highly recommended and computed tomographic pulmonary angiography is the gold standard in diagnosis of acute pulmonary embolism. Anticoagulants and thrombolytic therapy have shown a great success in treatment of acute pulmonary embolism. Surgical therapies (embolectomy and inferior vena cava filter replacement) proved to be lifesaving but many literatures favored medical therapy as the first choice. Prophylaxis pre and post operation is highly recommended, because there were statistical significant results in different studies which supported the use of prophylaxis in prevention of acute pulmonary embolism.Having reviewed satisfactory number of literatures, it is suggested that thoroughly preoperative assessment of patient conditions, determining their risk factors complicating to pulmonary embolism and the use of appropriate prophylaxis measures are the key options to the successful minimization or eradication of acute pulmonary embolism after lung resections.     

Technique of Pulmonary Thromboendarterectomy for Chronic Pulmonary Embolism

Pulmonary embolism infrequently results in severe chronic pulmonary arterial obstruction. However, when it does, affected patients are significantly symptomatic and have shortened survival. Medical management has proven ineffective. In the majority of surgical reports, unilateral thoracotomy with distal pulmonary arteriotomies has been emphasized. The average operative mortality was 22%. In this article, we discuss various preoperative considerations and describe in detail a surgical approach using median sternotomy for bilateral pulmonary thromboendarterectomy with cardiopulmonary bypass, deep hypothermia and circulatory arrest. With this standardized approach in 103 consecutive patients from October 1, 1984, to September 20, 1988, the hospital mortality (death within 30 days or during hospitalization) has been 11.7%.     

Pulmonary Paragonimiasis

Paragonimiasis is a food-borne zoonosis caused by a trematode of the genus Paragonimus.1, 2 Infestation is rare in Spain, but the influx of people from endemic areas should make us keep this condition in the differential diagnosis of our patients.2, 5We report the case of a patient from Ecuador and resident in Spain for 7 years with active pulmonary tuberculosis on arrival in Spain and later diagnosed with pulmonary paragonimiasis due to persistent haemoptysis. The diagnosis was established by surgical lung specimen showing granulomas containing parasite eggs and the macroscopic view of the fluke within a lung cavity. Initial tuberculosis treatment and current treatment with praziquantel controlled both conditions.     

Pulmonary aspiration

Aspiration may be defined as the inhalation of material below the true vocal cords. It occurs in patients with high gastric volumes or an incompetent lower oesophageal sphincter, or in those patients whose protective airway reflexes have been lost. Patients are most at risk during induction, emergence, and in the emergency situation. Aspiration causes a chemical pneumonitis, and particulate matter may cause airway obstruction. Consequences of aspiration include atelectasis, pulmonary oedema, VQ mismatching and the development of acute respiratory disease syndrome. The clinical presentation covers a wide spectrum and is influenced by the nature, pH and volume of the aspirate. Acute management includes airway suction, oxygen therapy and securing the airway if the patient is unconscious. Bronchoscopy may be required for large foreign bodies or semi-solid material in the airway. Those patients who develop clinical sequelae within 2 hours of aspirating require admission to high-level care for further treatment. Bronchodilators and physiotherapy are appropriate treatments. Antibiotics should only be given if infected matter is inhaled or if subsequent infection develops. Steroids do not improve outcome. Severe cases will require ventilation and management in intensive care. Mortality in those who develop symptoms is about 10%.     

Pulmonary hypertension

Pulmonary hypertension can arise in the presence of acute cardiopulmonary decompensation or develop as a chronic and progressive disease in association with connective tissue diseases, infectious diseases, or metabolic diseases, or in the form of idiopathic pulmonary hypertension. Impaired regulation of endogenous vasoactive mediators, growth factors, and thrombotic factors leads to pulmonary artery vasoconstriction, endothelial and epithelial proliferation, and thrombotic vascular obstruction, with resulting right heart failure. There is no curative treatment for chronic pulmonary hypertension, and the immediate objective of palliative treatment is to relieve right heart stress by reducing pulmonary arterial pressure with the aid of pulmonary vasodilators. Depending on the severity of the illness, perioperative mortality is high, which must be borne in mind by both anesthetists and intensivists. Chronic medical treatment for these patients must be optimized before any surgery is undertaken. In the perioperative period, it is essential that anything that could lead to worsening of pulmonary hypertension is avoided, or at least recognized and treated at an early stage. Intraoperatively, imminent acute right heart decompensation is treated by improving right-ventricular contractility and reducing right-ventricular afterload. In the postoperative period, monitoring and optimization of the cardiopulmonary status, adequate analgesia and sedation, and careful anticoagulation must be ensured.