M&M
VCU Department of Surgery
Division of Thoracic Surgery
James R Wade MD PGY-6
Rachit Shah MD Attending
Left VATS Decortication, Mechanical Pleurodesis
• Complication
• Death
CC / HPI
• 41yoF h/o OLT ’08 with 1 month progressive dyspnea, cough, fevers,
chills
•
•
•
•
Nebulizers and augmentin, no improvement
Large left pleural effusion
Transferred to VCU medical service
Started on Vancomycin / Cefepime
• PMH
•
•
•
•
•
PSC
UC
RA
HTN
TIA
• PSH
•
•
•
•
•
OLT ‘08
T&A
TAH
CSx
L shoulder and knee arthroscopy
• SH
• No A/T/D
• FH
• NC
• Meds
•
•
•
•
•
•
•
•
•
Amlodipine
Plavix
Mycophenolate Mofetil 1000mg BID
Tacrolimus 7mg BID
MgO2, FeSO4
Alprazolam
Oxycodone
Hydroxyzine
Fexofenadine
• Allergies
•
•
•
•
•
Amoxicillin
Levofloxacin
Gadolinium
Morphine
Shellfish, Chocolate
CC / HPI
• Interventional Pulmonology C/S
• Thoracentesis and BAL show parapneumonic process
• Incomplete drainage of effusion
• Evidence of loculations
• Transplant hepatology C/S
• Liver US: normal vasculature, no biliary dilatation, evidence of portal
hypertension
• Recommend decrease in immunosuppressants
OR
• L VATS decortication, mechanical pleurodesis
•
•
•
•
•
•
Multiple loculations and gelatinous material, no purulence
1.5L effusion
Non-expansive lung with thick pleural peal
Cx, AFB, fungals, GS
3 chest tubes
Extubated
Post Op
• POD#3
• MRICU transfer: Hypotension, respiratory distress
• Nephrology C/S: AKI due to hypotension and ATN
• Transplant ID C/S: Change to vancomycin, merropenum, posaconazole
• POD#4
•
•
•
•
•
Anuric, leukocytosis, hypoxia
Intubated, Bronchoscopy: diffuse mucous throughout
CRRT initiated
Tacrolimus level > 30
Started amphotericin B liposomal
Post Op
• POD#5
• Started levophed, vasopressin, hydrocortisone
• Linezolid
• POD#7
• CT C/A/P:
• Progression of multifocal airspace disease, mainly the RUL and bilateral lower lobes
• Severe anasarca, partial SBO with jejunal intussusception, dilated colon reflective of IBD
• Cipro / Flagyl
• Transplant surgery C/S
>30
Post Op
• POD#9
•
•
•
•
•
Gentamicin
Levophed up to 70mcg/min
Hypoxia, changed to Bi-Level ventilator mode
TTE, LE Duplex WNL
Elevated bilirubin
• POD#10
• HIT positive
• Tranaminases start to rise
• POD#13
• SBT, Wean to extubate, failed extubation, reintubated
Post Op
• POD#14-18
• Rising lactate, WBC, LFTs
• C diff negative
• CT C/A/P:
• Increased pericardial effusion, increased tracheal bronchial secretions, evidence of DAD-ALI-ARDS with
organizing pneumonia, new RUL consolidations
• Progressive diffuse colonic wall thickening consistent with pancolitis, widespread small bowel thickening,
three segments of jejunal intussusceptions, increased ascites, increased peritoneal enhancement
• Tp Surg: Abd S/ND/NT, no hematochezia, no diarrhea, findings most consistent with
hypoproteinemia
• Liver US: normal vasculature
• TTE: unchanged
• BLE toe dry gangrene
• ABIs / arterial duplex: WNL
• Vascular surgery C/S: due to sepsis and pressors, will need elective amputation, no immediate
intervention
Post Op
• POD#21
• Tracheostomy / Bronchoscopy: minimal secretions, mucosa normal
• CT C/A/P:
• Pneumomediastinum and subcutaneous emphysema, retained secretions, increase in
size of pericardial effusion, worsening airspace consolidations, DAD-ALI-ARDS with
organizing pneumonia
• Diffuse colonic wall thickening consistent with pancolitis, small bowel wall thickening, no
pneumatosis or portal venous gas, thickening of peritoneal surfaces, circumferential
bladder wall thickening, anasarca, mesenteric edema.
Post Op
• POD#25
• Increasing lactate, WBC
• CT A/P:
• Persistent diffuse colon wall thickening consistent with pan-colitis, thickened peritoneal
membranes and bladder wall, mutifocal splenic hypodensities
• Pulseless VT during transport
• Shock and several rounds of CPR
• Death
Culture Results
• Respiratory Culture: rare yeast, not Cryptococcus
• BCx: negative x 11
• Urine culture: negative
• Sputum culture: negative x 5
• Legionella: negative x 3
• AFB: negative x 4
• Cryptococcus: negative
• Fungal cultures blood and body fluid: negative x 7
• Nocardia: negative x 2
• Respiratory viral: negative x 2
• Histo / Blasto: Negative
• CMV: negative
• C diff: negative
• PJP: negative
• VATS Decortication and mechanical pleurodesis
• Death
• Nature of disease