Pneumonectomy

Pneumonectomy is an effective treatment for certain intrapulmonary or bronchial diseases. Depending on the nature, extent of the lesion and the patient's lung function, all lungs on one side (ie, pneumonectomy) can be removed; partial lung resection (including lobectomy, segmentectomy, or wedge resection) can also be performed; Lung lobe, or lung lobe plus lung segment (or wedge) resection; sometimes can be used for one or two (or staging) bilateral lung lobe or segmentectomy. For some patients, the mediastinal lymph nodes, pleural wall layer or part of the diaphragm are often removed while the lung or whole lung is being removed. In principle, the scope of lung resection should be sufficient, so that the lesions in the lungs are completely removed, and no recurrence can be left; but as little as possible, the normal lung tissue should be preserved as much as possible to maintain better lung function. Indication 1. Pulmonary laceration: severe lung laceration, can not be repaired, should be used for local lobectomy or pneumonectomy. 2. Bronchopulmonary tumors: The opinions on the scope of resection of malignant tumors have not been consistent. Most people believe that as long as there is no distant metastasis, the lymph nodes of one or two lobe and hilar, paratracheal and subcarinal lobe where the tumor is located are removed. The same effect as pneumonectomy can be obtained, but the surgical damage and complications can be reduced, and the postoperative lung function can be preserved more. For metastatic cancer that is confined to one leaf, or if the nature of the tumor is undetermined and cannot be ruled out as a benign tumor or tuberculoma, lobectomy should be performed. In summary, when considering the scope of resection, the type, location, metastasis, respiration, circulatory function, and patient's tolerance to surgery should be fully estimated. Such as lung cancer patients have cachexia, severe chest pain, fever; X-ray examination showed that the protuberance has been widened, the cancer shadow and the chest wall or mediastinum have been connected, no gap, or see pleural effusion; bronchoscopy see protuberance Widening and fixation, the tumor is less than 2cm from the bulge; the lactate dehydrogenase is more than 400 units, and the possibility of surgical resection is small, or can not be removed. If lung cancer has distant metastasis, or has invaded the phrenic nerve, recurrent laryngeal nerve and mediastinal vessels, contraindications are contraindicated. 3. Tuberculosis: Surgical treatment of tuberculosis is an integral part of the comprehensive treatment of tuberculosis and is only suitable for some patients with tuberculosis. Appropriate timing should be chosen and must be closely coordinated with other therapies to reduce treatment time, expand treatment coverage, and reduce recurrence rates. When selecting a treatment, the patient's general condition, type of disease, progression of the disease, and response to previous treatments must be fully considered and carefully determined based on the positive and lateral radiographs of the x-ray within the last 3 weeks. Under normal circumstances, patients with tuberculosis should first undergo a certain period of drug treatment, such as the lesion can not be cured, but suitable for surgery, that is, surgery should be timely, do not wait until all anti-tuberculosis drugs are ineffective after trial, so as not to miss the opportunity. In addition, when considering the surgical method, it is necessary to estimate the surgical effect, the burden of the patient, the degree of loss of lung function, and the possibility of recurrence of the residual lung lesion, and the safest, simplest, and effective surgery. At present, the risk and complications of pneumonectomy have been greatly reduced, but those who are not suitable for pneumonectomy should not be forced to use it. (1) Tuberculosis ball: The diameter is more than 2cm, and the drug treatment does not disappear after more than 6 months. Even if the center finds liquefied cavity or has an expanding trend, it should be removed. If the nature of the spherical lesion is not certain, it should not be waited for, and the surgery should be performed immediately. (2) Cheese lesions: cheese lesions or a pile of cheese lesions greater than 2cm, drug treatment for 6 months to more than 1 year is invalid, continue to sterilize, surgery should be considered. (3) Cavity: due to bronchial tuberculosis caused by granulation hyperplasia or scarring caused by stenosis, the distal cavity forms a tension cavity; or because of the long time of the lesion, the fibrous tissue around the cavity proliferates, forming thick-walled cavities, should be removed. Generally, the cavity is still not closed after the drug is actively treated for 6 months to 1 year. Regardless of whether or not the sputum is sterilized, surgery should be considered to avoid hemoptysis and dissemination in the future. (4) bronchial tuberculosis: active treatment of drugs for 6 months to more than 1 year of ineffective, even due to stenosis (or complete obstruction) caused by atelectasis; or due to extensive wall destruction, the formation of bronchiectasis, should be removed. (5) Destroy the lung: All or most of the lungs of one or one lobe are destroyed, forming cheese lesions, cavities, lung atrophy, fibrosis, bronchiectasis, emphysema, etc., should be considered for resection. If there are lesions such as cheese lesions, tuberculoma or cavities on the contralateral side, surgical problems should be carefully studied. (6) After the surgical collapse therapy, the cavity is still not closed in June to 1 year, and the acid-fast bacteria positive or intermittent positive is detected. When the patient's general health condition permits, the lung resection can be performed again. 4. Bronchiectasis: Bronchial angiography confirms the limitation of the lesion. If there are obvious symptoms, the diseased lung segment, lung lobe or whole lung should be surgically removed. If the symptoms are not obvious, surgery is not necessary. Such as bilateral bronchus have localized lesions, and the scope is small, can be resected, first cut the heavier side of the lesion; if there are still symptoms after surgery, confirmed by contrast from the contralateral side, and then the second surgery . The scope is too broad, and those who have no chance of surgery can only use body position drainage and Chinese and Western medicine treatment. 5. Lung abscess: After active medical treatment for more than 3 months, clinical symptoms and x-ray films are not improved, should be used for lobectomy or pneumonectomy. Because the range of inflammation is often extensive, it is not appropriate to consider the removal of the lung segment to avoid residual lung disease. For some extremely weak patients, the symptoms of poisoning are serious, can not tolerate lung surgery and the lesions are located in the superficial part of the lungs, and can be used for incision and drainage. 6. Others: Congenital pulmonary cysts, pulmonary bullae or pulmonary isolation, if symptoms appear, should be used for lung, lung or partial resection. All types of patients above should be tested for lung function before deciding on a pneumonectomy. If preoperative lung capacity and maximum ventilation account for more than 60% of the predicted value, lung surgery is safer; those below 60% should be treated with caution. In addition, if the patient has chronic heart and renal insufficiency, it will be difficult to tolerate surgery. Contraindications Pulmonary function tests should be performed prior to the determination of a pneumonectomy. If preoperative lung capacity and maximum ventilation account for more than 60% of the predicted value, lung surgery is safer; those below 60% should be treated with caution. In addition, if the patient has chronic heart and renal insufficiency, it will be difficult to tolerate surgery. Preoperative preparation 1. There must be a positive and lateral x-ray of the chest within 3 weeks before surgery in order to determine the location, extent and nature of the lesion; if the patient is a malignant tumor, there should be a chest radiograph within 2 weeks. In addition, chest fluoroscopy should be performed to observe the diaphragmatic activity to estimate whether there is sacral nerve involvement and pleural adhesion. 2. Pneumonectomy has a certain effect on respiratory function; especially after thoracoplasty after resection, the effect will be more serious. The more the range of resection, the greater the impact. Therefore, patients with lung resection should be asked in detail about the history of respiratory diseases, check respiratory function, and perform sub-pulmonary function tests if necessary to correctly estimate postoperative respiratory function. 3. Tuberculosis patients, especially those with irritating cough and sputum acid-fast bacteria, should be examined by bronchoscopy to determine whether the mucosa of the bronchial stump to be resected is normal, so as to avoid bronchial tuberculosis due to residual endobronchial tuberculosis. Serious complications such as pleural fistula and empyema. 4. For patients with pulmonary suppuration (including bronchiectasis), positional drainage should be strengthened, and appropriate antibiotics should be used according to the results of sputum culture and antibiotic susceptibility test, and the daily sputum should be reduced to a minimum (preferably at 50 ml). the following). The morning of the operation should be drained again to avoid sputum occlusion, suffocation, or secondary infection of the contralateral lung. Bronchoscopy and suction can be performed weekly if necessary. The effect of positional drainage depends on whether the draining bronchus is unobstructed, whether the patient's position is correct, and whether the time and number of fluid guiding positions are sufficient. In addition, it can also be combined with tinctures and bronchial expectorants. The position of drainage in different lung segments is shown in Table 1 (1 hour each time, 2 to 3 times a day): 5. In addition to the corresponding antibiotics in patients with suppurative disease before surgery, generally before the elective pneumonectomy, 1 day of injection of streptomycin and streptomycin should be given; tuberculosis patients should be injected with streptomycin and oral isoniazid before surgery. 1 to 2 weeks, penicillin was added 1 day before surgery. 6. Postoperative sputum and deep breathing can prevent complications and promote the expansion of the remaining lungs. If the posterior lateral incision is scheduled, emphasis should be placed on the early exercise of the upper arm in the early postoperative period to avoid adhesion of the scar near the incision and affect the arm activity. Surgical procedure 1. Position, incision: The position and incision of the pneumonectomy should be selected according to the patient's specific conditions and the lesion. Commonly used posterior lateral incision and anterior lateral incision, a simple lateral wedge resection, can also be performed through the infraorbital incision to reduce postoperative incision pain. 2. Separation of pleural adhesion: After cutting the chest wall and entering the chest cavity, the adhesion should be separated first, and the condition of the lung should be examined clearly before the lung surgery can be started. Adhesions should be completely separated for easy operation and also facilitate the expansion of residual lung after partial pneumonectomy. 3. Separation of the lung fissure: The fissures between the lungs are often incomplete or adhere to each other. In addition to pneumonectomy, they must be separated for surgical operation. Loose adhesions can be cut with scissors. If the adhesion is tight, or when the lung is not completely split, two hemostatic forceps can be placed in the lung fissure. After the forceps are cut, the needle is threaded from the lung door first, and the hemostat is sutured continuously to remove the hemostasis. Clamp, tighten the suture and then wrap it back for the second layer of continuous suture. This suture method prevents bleeding and prevents air leaks. Those with a wide range of adhesions can be clamped and cut and sutured in batches. If the bronchus and blood vessels of the lungs to be resected can be separated and cut off before the splitting of the lungs, the operation of the segmentectomy can be used to separate the incomplete pulmonary fissures, so that the residual lungs can be maximally expanded. 4. Treatment of hilar vessels: The key to pneumonectomy is the precise dissection of the hilum. The order in which the hilum is generally treated is to first cut the artery, then cut the vein, and finally cut the bronchus. However, if the artery of a certain part is behind the vein and cannot be first exposed, the vein can be cut first and then the artery can be cut off. If the movements and veins are not revealed, the bronchus can be cut first. For patients with lung cancer, the vein should be cut off first, and then the artery should be cut off to avoid blood transfer in the operation. If there is a lot of sputum, if there is a risk of suffocation or flow to the opposite side, you can also cut the bronchus and then treat the blood vessels. The movements and veins of the lungs are thinner than the blood vessels in other parts of the body, so the operation should be particularly careful. When separating the artery and vein, the connective tissue around the blood vessel should be separated first. The connective tissue that is in close contact with the wall of the tube is particularly dense, forming a film-like fibrous sheath that must be cut open to reveal a side wall of the blood vessel. There is a loose gap between the sheath and the vessel wall. The thin film can be lifted by a fine hemostatic forceps and gently separated by a small gauze ball to separate the blood vessels. The direction of pushing the small gauze ball should be directed to the blood vessel, perpendicular to the blood vessel, and should not be separated along the blood vessel. After separating the anterior wall of the blood vessel, the two side edges and a portion of the rear side wall can be separated. Finally, the right angle blood vessel separation forceps were used to penetrate the posterior side from both sides and carefully separated. The direction in which the jaw ends are separated during separation should be perpendicular to the vessel wall such that only one leaf side of the vessel separation forceps is in contact with the vessel wall and the other leaf is pushed toward the connective tissue surrounding the vessel to separate the vessel from the surrounding tissue. The vascular separation forceps should not be opened too much to avoid tearing the blood vessels. The open separation pliers should not be closed in situ, and should not be repeatedly opened and closed to avoid pinching the posterior wall of the blood vessel and even tearing the tube wall. After each time the separation forceps are opened, the forceps should be kept open in the open state, then the forceps will be closed and then extended into the posterior side of the blood vessel for a second separation. The left hand finger can also be used to penetrate the posterior edge of the blood vessel to guide the separation forceps to separate and protect the blood vessel from damage. After the clamp end is faintly exposed on the side edge of the blood vessel, the small gauze ball can be separated at the end of the clamp. Finally, the jaw end is tapped at the opposite side edge to completely separate the rear side wall. The length of the isolated blood vessel should be sufficient, generally more than 1.5 cm. For pneumonectomy, if the original anatomy is mutated, or the adhesion is too tight, can not be separated enough length, or the blood vessel near the pericardium is damaged or ligated and slipped, or the lung cancer is too close to the hilar, it can be in front of the phrenic nerve ( Or the rear) Cut the happy bag, separate the movements and veins in the pericardium, and ligation and cutting. If necessary, remove the local pericardium from the lungs. In the case of lobectomy, part of the lung tissue can be separated, and the distal branch vessels are exposed and separated. After the blood vessels are separated, the No. 4 (or No. 7) thread can be clamped to the separation forceps placed on the back side of the blood vessel according to the thickness of the blood vessel. The wire is taken out from the posterior side and ligated separately. End and far end. If the isolated blood vessels are too short, the distal branches should be ligated separately. Pulmonary blood vessels are very brittle, the force should be averaged when ligating, not too tight, and can not be loose. When the thread is tightened, the pulled lung tissue must be relaxed, so that the blood vessel is in a relaxed state and is not easily torn. The proximal and distal ligatures should be of sufficient length (at least 0.5 cm) to allow the staggered vessel stump, especially the proximal end, to form a flared enlargement. If there is more than one branch at the distal end, it can be cut off on the branch, so that the proximal ligature is not easy to slip off. In order to avoid slippage of the ligature line, before cutting off the larger blood vessel, a 0-1 wire thread should be sutured on the proximal side of the distal and distal ligatures of the proximal ligature. The suture site should be close to the ligature, so that the sutures at both ends are kept long enough, and then the blood vessels are cut (or cut). Do not use clamps when cutting, so as not to be broken. If the length of the blood vessel is small or the length of the blood vessel is not enough, and it is not possible to add two sutures, the suture can be added only at the proximal end, and the distal end can only be cut with a hemostatic forceps and then cut, and then the distal end is ligated. Or suture in the adjacent lung tissue, the distal end is only cut with a hemostatic forceps and then cut, and then the second distal ligation, or suture in the adjacent lung tissue. As for the very fine blood vessels, especially the veins, there is no need to sew, just two ligatures. If the blood vessels are thick, especially the trunk of the pulmonary artery or the inferior pulmonary vein, thick lines or double lines should be applied during ligation to prevent the line from cutting the wall and causing major bleeding. The proximal suture line should not be too thick to avoid slipping; but the distal end seam can be thicker or doubler, which is easier to tighten. If the proximal end is too short or the suture is not strong, the broken port can be sutured continuously in a single line to avoid suture slippage, or even indented into the pericardium without being detected, causing fatal bleeding. 5. Treatment of the bronchus: Before the bronchus is separated, the lymph nodes near the bronchus can be removed first to facilitate the exposure; if it is a lung cancer, the hilar lymph nodes should be removed. Then, under the guidance of the finger, the lung tissue is pushed open with a gauze ball and a long curved forceps, and the bronchus to be cut is separated by 1 cm or more. There are often two obvious bronchial arteries in the posterior wall of the bronchi, and one of the upper and lower edges, respectively, should be sutured. The suture site should be close to the plane of the bronchial preparation to cut off, so that the bronchial stump has enough blood supply to facilitate healing. If the bronchial artery cannot be seen beforehand, the bleeding can only be clamped immediately after the bleeding point is cut, and then ligated or sutured. The plane of the bronchus should be close to the bifurcation of the adjacent lung bronchus; if the whole lung is removed, the bulge should be close to the protuberance, so that the bronchial stump is shortened as much as possible, and no secretions are accumulated in the stump after the operation to cause infection. After the separation is completed, a bronchial forceps is placed on the near lung side, and the clip is lightly clamped. In the lobectomy or segmentectomy, the lungs can be inflated. If the lungs ready for resection are no longer dilated, and the rest can be opened, the bronchial forceps can be clamped without any errors. A needle thread was pulled from each of the upper and lower edges about 0.5 cm proximal to the bronchial bifurcation, and the bronchus was cut by the assistant and then the bronchus was cut between the bronchial forceps and the traction line. In order to avoid excessive leakage from the bronchial stump and affect the breathing, the suture can be cut intermittently, the suture can be tightened, and finally ligated one by one; or cut once and quickly sewed. If the bronchial tube is thicker and the bronchial cartilage ring tension is too large, which affects the suture tightening, the cartilage ring can be longitudinally cut at the upper and lower edges of the stump to reduce the tension. The suture can be used with 0 to 3-0 filaments. The distance between each needle and the edge of the broken end should be kept at an equidistance of 3 mm, so that the tension is averaged, so that a certain suture does not divide the tissue due to excessive enlargement, causing serious complications of shedding and bronchopleural fistula. If there is a lot of bronchial tract, or there is more blood flowing into the stump, the attractor head can be attracted to the stump before the suture is tightened to prevent secretions or blood from flowing into the opposite side, causing dissemination or secondary. infection. For example, the bronchus can be separated longer, and the diseased lung can not shrink when it is inflated. When affecting the operation of the bronchus, two bronchial forceps can be clamped first, and the bronchus is cut between the forceps to remove the diseased lung. Then, the second side was sutured at the proximal side of the proximal bronchial clamp site and 0.5 to 0.8 cm proximal to the bronchial bifurcation. If the bronchus is blocked by lymph nodes or lung parenchyma, it can not be separated for a long time, and the diseased lung can not shrink, affecting the visual field, even if the two bronchial forceps can not be placed, you can first clip a bronchial forceps and cut the distal side of the forceps. The distal bronchus was clamped with tissue clamps, and after complete severing, the diseased lungs were removed and the proximal stump was trimmed. The method of suturing the bronchial stump, in addition to the intermittent full-layer suture, there are two methods: First, the mucosal external suture method, that is, first use the heart ear pliers to clamp the residual, separate and remove 1 or 2 cartilage rings, so that the mucosa is free, Then, the soft tissue of the wall outside the mucosa is sutured intermittently to make the mucosa varus. This method can make the stump closure more tight, and the suture does not penetrate the whole layer of the tube wall, so that the secretion in the stump does not flow along the suture to the outside of the bronchi, causing infection, but the operation is more complicated. Another method is to simply ligature the bronchial stump with a thick thread and add it as a 4-0 line. This method can only be used in thinner bronchial tubes and should not be used for thicker bronchial tubes. Due to the large elastic force of the thick bronchial cartilage ring, the ligature is not easy to tighten, and the wire is easy to cut off the wall, and the distal blood supply of the ligation is blocked, which will affect the healing of the stump. For bronchial stumps or rough surfaces of the remaining lungs, check for leaks. The examination method can fill the chest cavity with warm saline, and at the same time pressurize and inflate through the endotracheal tube to observe whether there is bubble leakage. If the bronchial stump leaks, it should be added as a broken silk suture or suture suture. The leakage of small alveoli in the rough surface of the lung can be stopped after being covered with cellulose within 24 hours after surgery, without suturing, so as not to affect the expansion of the residual lung; if the rough surface has a large leak, it should be sutured. After suturing the bronchial stump, it should be covered with surrounding lung tissue or connective tissue. The right side can be covered with connective tissue around the pleural or azygous vein in the hilar region; in addition to the mediastinal pleura on the left side, a pericardium can be used or a pleural flap can be separated in front of the aorta. The covering should be in close contact with the bronchial stump to strengthen the stump and promote healing. 6. Lung resection: See the lung resection steps at each site. 7. Chest wall suture: Before suturing the chest wall, you must carefully check for residual active bleeding points. In the pleural adhesion separation, extrapleural detachment, pericardium, hilar, residual lung rough surface, face, rib fracture and incision muscle section, especially at the ends of the incision, are easily overlooked bleeding or oozing sites, should Repeated examination, according to the specific circumstances, coagulation, ligation or suture, completely stop bleeding. (1) Place the drainage tube: After the whole lung resection, a drainage tube can be placed between the 8th or 9th intercostal space, the posterior tibial line and the midline line. Firstly, the drainage tube is clamped and not drained. For example, if there is excessive bleeding in the thoracic cavity, the intrathoracic pressure on the operation side pushes the mediastinum to the healthy side, so that when the breathing is affected, part of the effusion can be intermittently released to adjust the intrathoracic pressure. After the upper lobe is removed, the drainage tube should be placed in the 8th or 9th intercostal space to drain all the exudate in the chest; a thin drainage tube can be placed in the second intercostal clavicle to discharge the chest. Gas accumulation is beneficial to the expansion of the lungs. After the middle, lower lobe or small segment of the lung is removed by wedge, only the eighth intercostal space is drained. (2) Rinse the chest cavity: According to the chest cavity contamination and hemorrhage, rinse with warm saline for 1 to 3 times. (3) suture the chest wall. complication (1) Postoperative intrathoracic hemorrhage: intrathoracic hemorrhage after pneumonectomy, forced to re-enter the chest to stop bleeding, accounting for about 1% of lung resection. Causes: 1 pleural adhesions bleeding or oozing, usually in the top of the chest; 2 chest wall vascular injury after bleeding, such as intercostal artery or internal thoracic artery bleeding, due to bleeding from the systemic circulation, higher pressure, not easy to stop; 3 The large blood vessel damage of the lungs is mostly caused by the loosening of the ligature line, and the blood loss is fierce, and it is often too late to rescue. Treatment: In any of the following situations, you should not hesitate to seek early chest exploration and stop bleeding, and prepare enough whole blood to supplement the lack of blood volume. 1 The blood volume of the closed thoracic drainage tube is 150-200ml per hour in 5h; 2 the blood drawn out quickly solidifies, indicating that there is a large active bleeding in the chest; 3 bedside chest X-ray shows The affected side has a larger density of the film, the lung is compressed, the mediastinum shifts to the healthy side, the patient feels difficulty breathing, indicating that there are more clots in the chest; 4 patients have hemorrhagic shock, although the whole blood is given and the antibiotic is given Shock measures, but no improvement in blood loss symptoms. Surgery usually involves the original incision into the chest, sucking the blood in the chest and clearing the clot. If the blood in the chest is not polluted, and the patient is in urgent need of blood supplementation, consider adopting the method of autologous blood return, that is, adding blood and filtering the appropriate amount of antibiotics to return. If the patient's blood pressure is not too low, the active bleeding point can be found after the chest is opened, and the bleeding is stopped. Sometimes after the blood clot is removed, no bleeding can be found. If this situation is encountered, wait for about 10 minutes. If you have not seen the bleeding point, you can safely close the chest. There is very little rebleeding after surgery. In recent years, with the increase in bronchoplasty, bronchial-pulmonary spasm has led to fatal bleeding in the chest. Some authors have a statistical rate of 3%. The reason is that there is a small sputum in the bronchial anastomosis, causing a small abscess, and a small abscess erodes the nearby pulmonary artery. The prevention method is to free a piece of pleura or other tissue during surgery to isolate the bronchial anastomosis from the pulmonary artery. (2) cardiac complications 1 cardiac spasm: pericardial incision or partial resection without suturing or repairing, postoperative cardiac spasm may occur. This complication is rare, but it is very dangerous and the mortality rate is as high as 50%. It usually occurs after pneumonectomy, but there are also reports of heart failure after lobectomy. Typical clinical manifestations are sudden hypotension, tachycardia, and cyanosis. The cause is suction in the chest, suction in the trachea, severe cough, position change and positive pressure ventilation. Diagnosis is extremely difficult, mainly based on vigilance and experience. The emergency chest X-ray film is very helpful for judging the right side of the sputum. It can be seen that the heart is displaced from the original to the right side, but it is difficult to judge the left side. The right iliac crest not only causes the upper and lower vena cava to twist, but also causes the left ventricular outflow tract to be distorted and blocked. The left iliac crest is a true stenosis, which can seriously affect left ventricular filling and ejection and myocardial blood supply. ECG can show similar myocardial infarction. Once the clinical consideration of the possibility of cardiac spasm, the patient should be immediately placed on the healthy side, and individual patients may have a cardiac arrest. If the condition does not improve, it should be decisively open at the bedside for chest exploration, cardiac arrest and pericardial defect repair. There are several methods for repairing right pericardial defects, including epicardial and pericardial fixation, artificial materials or autologous tissue repair. If the left pericardial defect is enlarged downward to the diaphragm, it may not be repaired. At this time, although the heart is very severe, it is not easy to be narrowed and infarcted. 2 cardiac tamponade (pericardial tamponade): open the pericardium during lung resection, may miss the treatment of bleeding points, resulting in blood accumulation in the pericardium. When the blood in the pericardium reaches a certain level, hypotension, central venous pressure, odd pulse, and heart failure may occur. Ultrasound and X-ray examination can confirm the diagnosis. Treatment should quickly drain the blood in the pericardium, open from the original incision in the chest, or make an incision under the xiphoid process. 3 arrhythmia: patients over the age of 60 often have arrhythmia after lung resection. The incidence after pneumonectomy is 20% to 30%, and 15% to 20% after lobectomy. Among all arrhythmias, atrial fibrillation is the most common, followed by sinus tachycardia, atrial flutter, ventricular extrasystole, knot rhythm, chronic arrhythmia, and bipolar law. Paroxysmal atrial tachycardia with block, multi-source atrial tachycardia, ventricular tachycardia, sick sinus syndrome and atypical ventricular tachycardia are relatively rare. More than half of the arrhythmias occurred in the first 24 hours after surgery, and the peak period was 2 to 3 days after surgery. The cause of arrhythmia is not yet clear. It has been suggested that it is related to mediastinal shift, hypoxia, abnormal blood pH, vagus nerve stimulation, etc., but it has not been confirmed. However, elderly, patients with coronary heart disease, preoperative electrocardiogram showed atrial or ventricular premature beats, complete or incomplete right bundle branch block, pneumonectomy in the pericardial vascular, intraoperative hypotension Post-prone arrhythmia has been recognized by everyone. Postoperative arrhythmias, especially persistent or recurrent supraventricular tachycardia, not only prolong the length of hospital stay, but also increase the risk of perioperative period. It has also been suggested that postoperative arrhythmias affect the long-term survival of lung cancer patients. In this case, do you need preventive medication before surgery? So far, there is still debate. Opponents believe that preventive medication is not only ineffective, but also has side effects and dangers. Treatment: In some patients, the heart rhythm returns to normal without special treatment. Some patients, only sporadic atrial or ventricular premature beats, or transient atrial fibrillation, can also be closely observed without special measures. However, most patients require medical treatment, and fatal arrhythmias require urgent treatment. The treatment of arrhythmia is first to remove the cause, such as improving hypoxia, proper sedation and analgesia, correcting water and electrolyte disorders, and maintaining acid-base balance. Then apply different drugs or take other measures depending on the type of arrhythmia. Rapid atrial arrhythmia can be used for digitalis preparations. Adults should use 0.8 to 1.2 mg in general. Verapamil (isopidine) is effective in terminating rapid supraventricular arrhythmia. For the first time, it is slowly pushed 5-10 mg, and if necessary, repeated 10 to 15 minutes later. After supraventricular arrhythmia control, changed to verapamil orally, 40 ~ 80mg, maintained 3 times a day. Synchronous DC cardioversion should be used for atrial arrhythmias that are ineffective for medical therapy and have hemodynamic disorders. The first choice for ventricular tachycardia medication is lidocaine, 50 ~ 100mg intravenous bolus, and then continued to maintain intravenous infusion of 1 ~ 2mg / min. Atropine or intravenous isoproterenol can treat bradycardia. When a third degree atrioventricular block or sick sinus syndrome occurs, an artificial cardiac pacemaker should be considered. 4 myocardial ischemia and myocardial infarction: It has been reported that the incidence of asymptomatic myocardial ischemia after pneumonectomy is about 3.8%, patients with coronary heart disease and those who have had myocardial infarction are prone to occur, often after the second postoperative ~ 4 days appeared. Therefore, strict cardiac monitoring should be performed after pneumonectomy. Once diagnosed, enteric-coated aspirin can be given, 160-325 mg daily. It has been suggested that appropriate beta blockers should be used to prevent myocardial infarction and death. The incidence of myocardial infarction after pneumonectomy is about 1.2%. Preoperative diagnosis of coronary heart disease is easy to occur, and the mortality rate is as high as 50% to 75%. Once diagnosed, you should urgently consult the cardiology department for assistance. 5 orthostatic hypoxemia: after pneumonectomy or lobectomy (usually right upper lobe or upper right or middle lobe), the patient has no or slight dyspnea in the supine position, and the oxygen saturation is normal or slightly lower than normal, but When the patient sits up or stands up, dyspnea or dyspnea is aggravated, and the oxygen saturation becomes abnormal or further decreased. This is called "orthodeoxia". There are 24 reports in the literature. The reason for this is a change in the position of the heart after pneumonectomy, which causes the blood of the inferior vena cava to flow to the patent foramen ovale or atrial septal defect, resulting in a right-to-left shunt. Cardiac ultrasound, cardiac catheterization and cardiovascular angiography can help with diagnosis. Closed to the foramen ovale or atrial septal defect can be cured after the diagnosis is clear. (3) pulmonary complications 1 pulmonary edema after total pneumonectomy: total lung resection, especially after right pneumonectomy, if there is progressive dyspnea, cyanosis, tachycardia and irritability, cough pink foam sputum and lungs full of wet A voice should be diagnosed as pulmonary edema after pneumonectomy. Although the incidence is not high (about 2% to 5%), the mortality rate is high (7% to 80%). The mechanism of this complication is not yet clear, but clinical observations and experiments have shown that excessive fluid input during the perioperative period is an important cause. Since the fluid filtered from the pulmonary capillaries exceeds the ability of lymphatic reflux, the fluid begins to accumulate in the space around the small bronchi, the lungs become stiff and the work of breathing increases. When the gap around the small bronchi is completely filled with water, the alveoli are also quickly involved, so hypoxemia occurs and even death.

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