A 53-year-old male patient was diagnosed with malignant pleural mesothelioma.
After previous tumor resection and chemotherapy, she had recurrence and her oncologic committee recommended a new surgical intervention.
She was intubated with a Mallinckrodt (39F) double-lumen tracheal tube and lateralized for surgery.
Upper and lower left Pathways, total left pleuropneumonectomy, pericardiotomy and resection of the ipsilateral hemidiaphragm were performed.
During the surgery he presented massive hemorrhage requiring crystalloids (13 L), colloids (2 L), red blood cells (11 U), platelets (6 U) and fresh frozen plasma (7 U).
After the pericardiotomy, she presented two episodes of ventricular fibrillation and severe bradycardia that were successfully treated.
Upon admission to the ICU, the patient was hypothermic (35°C), tachycardic (115 beats x min), with blood pressure of 170/90 mmHg and signs of distal hypoperfusion.
No detailed neurological evaluation was performed due to the fact that the patient was suffering from muscle relaxants.
Initial examinations showed: hematocrit 23% (46% preoperative), platelets 71,000 mm3, INR 2.1, mixed venous saturation (Sv02) 6l%, arterial lactate 7.99 mmol/L, troponin I 100MBinkinase 5314 U
Arterial blood gases with FÍ02 of 50% were: Pa02 107 mmHg, PaC02 44 mmHg and HC03st 20 mEq/1.
Hemodynamic management included volume replacement, vasodilators (nitroglycerin) and inotro-pos (milrinone and dobutamine).
Protective ventilation was initiated in volume-controlled mode, with tidal volume of 380 mi (5.5 ml/kg ideal weight), respiratory rate of 24 per min, PEEP 8 cmH20 and FÍ02 of 50%.
With these parameters, the plateau pressure was 27 cmH20 and the mediastinal shift was reduced.
High blood output was observed by pleurostomy during the first 24 h.
She developed hemodynamic instability and coagulopathy was intensified.
In this context, the administration of hemoderivatives, "controlled hypothermia" and pleurostomy (4 h) were performed transiently, permanently evaluating the hemodynamic trend and respiratory mechanics.
The bleeding was controlled and the patient improved his clinical condition progressively.
On the fourth postoperative day, her pulmonary function worsened, with arterial blood gases arriving at FÍ02 90% and PEEP 12 cm H20 to Pa02 72.8 mmHg, PaC02 62 mmHg and HCl>3st
The Pa02/Fi02 and grading index were 80 and 21, respectively.
Lung distensibility fell to 20 mi/ cmH20 (mainly due to increased extravascular lung water) and did not respond to relapsed maneuvers (RM).
Pressure-controlled ventilation was programmed for 1 min inspiratory pressure 20 cm H20, PEEP 20 cm H20, I/E ratio of 1:1 and respiratory rate 15ick per min, after which PEEP was modified according to Hling strategy.
Chest radiography showed decreased right lung volume, pleural effusion and associated interstitial-alveolar involvement.
We decided to use PPV according to our severe ARDS algorithm.
The patient remained seated in PPV for 36 h. Respiratory variables improved during PPV, without hemodynamic variations, or denouncing pressure ulcers.
The patient returned to the supine position without deterioration in her condition.
The control chest X-ray showed improvement in lung volume and parenchymal involvement of the remaining lung.
In the second week of ICU stay, the patient presented a peri- and respiratory infection collection, both successfully treated.
A mechanical ventilator was deconnected on the 18 postoperative day and the patient was discharged one month after admission.
Until now, 3 years later, the patient remains active and has good quality of life.
