• Twitter
  • Facebook
  • Vimeo
  • FCUS Courses
  • Register for FCUS Course
  • Login
Intensive Care Network
  • About Us
    • What is ICN
    • Our Team
  • Events
  • Podcast Series
    • Podcast by Topic
      • Airway Podcasts
      • Cardiac Podcasts
      • Career Podcasts
      • Conference Podcasts
      • Education Podcasts
      • Evidence Podcasts
      • GI/Renal Podcasts
      • Haem Podcasts
      • Metabolic Podcasts
      • Miscellaneous Podcasts
      • Neuro Podcasts
      • Paeds Podcasts
      • Respiratory Podcasts
      • Resuscitation Podcasts
      • Sepsis Podcasts
      • Toxicology Podcasts
      • Trauma Podcasts
      • Ultrasound Podcasts
    • Podcast by Specialty
      • Anaesthetics
      • Emergency
      • ICU
      • Prehospital
    • SMACC
    • ICN
    • Jellybean
    • CICM ASM
  • Blog
  • Resources
    • Clinical Cases
    • Fav Posts/Other Sources
    • Game Changing Evidence
    • Radiology
      • ICU Radiology
    • Simulation Resources
    • Ultrasound
      • Lung Ultrasound
  • EXAMHELP
    • ANAESTHETICS PRIMARY
    • ANZCA FELLOWSHIP
    • CICM Fellowship
    • EMERGENCY PRIMARY
    • ICU Primary Exam
    • PAEDS FELLOWSHIP
  • Contact Us

Radiology Case 10

Home Radiology Case 10

ICU rad_pic 

By Dimity McCracken

These are images from real ICU patients. The stories and details are changed to preserve confidentiality.

[su_tabs][su_tab title=”History”]

This patient has just returned from cardiothoracic OT. He is ventilated & haemodynamically stable. The nurses mention that the right chest drain is clamped, & ask you if the chest drain should be placed on suction. How do you answer?

[/su_tab][su_tab title=”Image”]

rad10a
[/su_tab][su_tab title=”Answer”]

The patient has had a right pneumonectomy. Tell the nurse to leave the chest drain clamped.

The arrow shows the surgical clips over the R bronchial stump. The pneumonectomy looks like a poorly defined but massive pneumothorax. No lung edge is discernable. There is mediastinal shift TOWARDS the right side (the opposite of what one would find if this was a tension pneumothorax). The patient is intubated. There is a right IJ CVC & right ICC visible. Nasogastric tube is appropriately positioned with tip below the diaphragm. Sternal wires are seen (although most pneumonectomies are approached via a thoracotomy). There is some mild L basal atelectasis.

rad10aa

This is their CXR 2days later, once the patient has been extubated & chest drain removed. There has been gradual accumulation of pleural fluid.

rad10b

[/su_tab][su_tab title=”Management & Resources”]

Management of post-op pneumonectomy patients:

-Ventilation is low pressure ventilation to avoid blasting clips off the bronical stump clips. In addition the pleural pressure is more negative post-op. Thus the remaining lung is hyper-expanded with decreased compliance.

-Do NOT put chest drain on suction! Often leave ICC clamped with intermittent brief unclamping to help regulate pressure on the surgical side, & also to check for post-op haemorrhage. If the ICC is placed on suction it will remove all the air from the surgical side ? no lung available to re-expand that side ? sucks mediastinum across, which then kinks the great vessels ? haemodynamic collapse (similar to tension pneumothorax, except this mediastinal movement is towards the surgical side).

-Post-op haemorrhage can be torrential, so needs to be carefully monitored. Have a very low threshold for a repeat CXR.

-Fluids: keep the patient dry! Immediately post-op these patients are extremely prone to developing pulmonary oedema. Pre-op both lungs received the cardiac output, while post-op this whole output goes through the only remaining lung. This makes the lung very sensitive to any excess fluid & prone to injury (ALI) in addition to the significant reduction in pulmonary reserve.

-Evans article on conservative fluids in lung resection

-Pleural effusion fluid should gradually accumulate over a few days, as air is resorbed. By about 2wks the effusion is clearly visible on CXR: no meniscus sign!

-Very aggressive pulmonary toilet is needed: chest physio, early mobilisation, aggressive management of secretions (including bronchoscopy if required). Due to the acute reduction in pulmonary reserve, these patients do not tolerate any sort of lung insult.

[/su_tab]
[/su_tabs] 

Share this
SMACC: John Vassiliadis - Courage Under FireSIMWARS GOLD: A New Hope
IPSN – Intensivist Parent Support Network WIN – Women in Intensive Care Network ICN UK ICN NZ ICN WA ICN VIC ICN NSW ICN QLD The ICN Story The Team Jellybean Podcasts ICN Blog SMACC Video SMACC Audio Video ECG Simulator by aclsmedicaltraining BASIC SCIENCE CLINIC Simulation Game Changing Evidence ICU Radiology Echo Guide ECHO Cases Clinical Cases EXAMHELP Jellybean Podcasts ICN Blog SMACC Video SMACC Audio Video CICM Fellowship ANZCA FELLOWSHIP PAEDS FELLOWSHIP EMERGENCY PRIMARY ANAESTHETICS PRIMARY End-o-bed-o-gram

  • About
    •  What is ICN
    •  The Team
    •  ICN NSW
    •  ICN QLD
    •  ICN VIC
    •  ICN WA
    •  ICN NZ
    •  ICN UK
  • Resources
    •  Lung US
    •  Exam Help
    •  Clinical Cases
    •  Echo Cases
    •  Echo Guide
    •  ICU Radiology
    •  Game Changing Evidence
    •  ICN Metafeed
    •  Simulation Resouces
  • Media
    •  SMACC Posters
    •  Audio
    •  Video
    •  Pecha Kuchas
  • Upskill
    •  Clinical Cases
    •  Echo Cases
    •  ICU Radiology
  • Exam Help
    •  End-o-Bed-o-Gram
    •  ICU Primary Exam
    •  CICM Fellowship
    •  ANZCA Fellowship
    •  Paeds Fellowship
    •  Emergency Primary
    •  Anaesthetics Primary

® 2021 The Intensive Care Network || All rights reserved || Disclaimer || Site Map || Contact ICN Support

Log in with your credentials

or     Create an account

Lost your password?

Forgot your details?

I remember my details

Create Account