[HSF] Unilateral lung white out

[erdinç naseri]

Prasanna ,
Anything which coulld theoretically obstruct the ostia of the pulmonary 
veins?Obviously it's a unilatral pathology and this leads us more to the 
local pathologies rather than systemic ones (ARDS,pump lung,...).As you 
mentioned you could have replace ETT with Carlene's tube for unilateral lung 
ventilatiion.You have done whatever could be done.Sorry for the loss which 
is much painfull when it is a child.
erdinc


>From: prasannasimha <prasannasimha at gmail.com>
>Reply-To: OpenHeart-L at lists.hsforum.com
>To: "OpenHeart-L at lists.hsforum.com" <OpenHeart-L at lists.hsforum.com>,ccm 
><ccm-l at ccm-l.org>
>Subject: [HSF] Unilateral lung white out
>Date: Tue, 13 Mar 2007 19:02:00 +0530
>
>8 year old child underwent mitral valve repair +TV repair + emaze. Child 
>had a bout of atrial flutter which was terminated with a shock prior to 
>cannulation.Cordarone was added to the pump. Patient underwent a TV plasty 
>with a Goretex Band and the repair involved using a complete 28 mm Goretex 
>ring.
>MVOA was 2.1 and trivial MR on epicardial echo. Child was transiently 
>bradycardic  and needed a short period (2 hours) of Isoprenaline which was 
>stopped and was just on 3 mic dobut + SNP which was going to be weaned off 
>when the child fully rewarmed.
>Within an hour after surgery the child's temperature shot upto 39.4 C 
>Nasopharyngeal and tachycardia occurred and it was managed by cooling 
>topically + cold saline RT wash . Al inotropes were stopped and child was 
>only on a small dose of SNP and thereafter for the next 6 hours was doing 
>well. There was a slight drop in saturation's  and this was managed by 
>suctioning (minimal secretions) and PEEP of 12 (was being ventilated @ 40 
>FIO2, , 7ml/Kg tidal volume and 10 PEEP which was increased to 12. The sats 
>normalized. 3 hours after that I got a call that some secretions - yellow 
>and straw colored were coming from the ET tube and the left lung was having 
>creps whereas the right was clear. Over the next 2 hours this increased and 
>despite suctioning and increasing the PEEP to 14 and a chest X Ray done at 
>this time showed a while left hemithorax and I was told an effusion was 
>suspected so a tap was done showing some fluid and a chest tube was placed 
>with only 150 ml of fluid coming out. The white out was of the lung obvious 
>in the repeat X ray.
>In the meanwhile the fluid coming out of the ETT was increasing so I asked 
>for a repeat Echo. The Echo window was poor but the Echo-cardiographer said 
>that there was no MR and could not comment on the MVOA but there was no 
>flow acceleration across the mitral valve though the mitral valve motion 
>looked "restricted" .
>I asked for a Swan to be floated and with a systemic  pressure of 92/45 the 
>PA pressure was 25/16 and the CVP was 10 and the PCWP was 11.
>In the meanwhile the child's condition was worsening  and it was difficult 
>to manage the lungs an secondarily hemodynamic instability started wafter 
>crashing Sats. PEEP higher than the wedge pressure was now totally 
>ineffective So I planned to put the child on CPB for ECMO/ look at the 
>mitral valve again and plan further management but by the time we could do 
>it the child arrested in the ICU - The chest was opened and there were no 
>clots compressing the pulmonary veins etc. Massage was continued for some 
>time - the left lung was "solid and soggy" while the right lung was 
>ventilating normally and "aerated". The child could not be revived.
>In the mean while we had sucked out a total of 800 ml of proteinaceous 
>fluid with Albumin levels same as blood (In the melee in trying to keep the 
>child alive we did not realize that it was so much  !!)-  not pink frothy 
>like pulmonary edema but looking more like that of pulmonary alveolar 
>proteinosis lavage (If you get what I mean)
>I am still not sure what this was and am not sure what to do if it happens 
>again. May be I would have placed the ETT in the right lung endobronchially 
>to at least protect the right lung.
>Comments / suggestion.
>For some time I was toying with the idea of a mucus plug - collapse and re 
>expansion pulmonary edema etc etc but we never had evidence of a blockage 
>and there was continuous "plasma like" fluid coming out. Another thought 
>was CPB induced lung injury - but why unilateral
>Incidentally at the end of it all the fluid which was in the suction bottle 
>formed a froth on the top which solidified into a soapy mass !!
>I forgot to get the camera today so I will send the X Rays tomorrow.
>Prasanna
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