Considerations for Chest Wall Surgery Patients in the ICU

Podcast Transcript

Announcer:

Welcome to Cleveland Clinic Cardiac Consult, brought to you by the Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute at Cleveland Clinic.

Daniel Raymond, MD:

My name's Dan Raymond, I'm a thoracic surgeon. I'm head of the Chest Wall Center at the Cleveland Clinic. Today we're going to talk about chest wall physiology, chest wall surgery and the implications of management in the ICU.

Chest wall procedures, and there's kind of a group of different ones that all have a common theme. The boles thoracoplasty, you'll never see this in the literature. It's because it's only done here. This is the first patient to ever have this surgery, Carl Boles. And essentially it's the treatment of this very rare syndrome called acquired thoracic dystrophy. And what happened in acquired thoracic dystrophy is the patients underwent at a very young age, there was a time where people with pectus excavatum, pediatric surgeons were saying, "We are going to fix them as soon as we see them." So, they take a two-year-old to the operating room to fix their pectus with the older procedure, the Ravage procedure.

And the Ravage procedure, you take out the cartilage, but you're supposed to preserve the lining around the cartilage and allow it to regrow. And what they did is they ended up destroying the growth plates of the ribs. And so people with acquired thoracic dystrophy had a Ravage as a child and now have severe restricted lung disease because their chest never grew. So, they have the chest of a seven-year-old, and they have a very characteristic body habitus with this kind of bell-shaped rib. And so they have severe restrictive disease. So we're trying to develop a procedure to address that. And it's just at this point, the technology is relatively limited, but essentially trying to expand the chest out, which means cutting the ribs in multiple locations and expand the chest out.

What's fascinating is when you do it, the lungs love it. The lungs immediately fill into the space. The lungs did not stop growing. They're just squeezed in there and uncomfortable. And so they are very happy. The challenge is you just gave someone 16 rib fractures, and let me tell you, they hurt. And so what I do is I do hinge cuts in the back. So I do little half cuts in the ribs in the back to create a green stick fracture and allow the rib to open up and then completely divide the rib from the sternum in the front. And then if there's too much space, I put pieces of cadaveric tibia in to bridge the space. And then everything gets covered with plates. And that's why you see tons of plates in these people.

If you're lucky, you'll get a 10% improvement in chest volume. So they still have fairly significant restrictive lung disease. They're going to have all the challenges of dealing with restrictive lung disease.

Chest wall resection, another procedure we do a moderate amount of. It's a fairly rare procedure. If you look at all of the STS contributing thoracic centers in the country, and there are about 400 of them, the average number of chest wall resections done is zero. It's a relatively rare procedure concentrated at a few centers, and we do a fair number of them, and we're taking out large pieces of the chest wall. And again, you're disrupting chest wall function. You're trying to recreate it. Again, the same challenge, pain.

Pectus excavatum... How a Ravage is done. You have a sternum that's depressed, and what we do is we take out what's called the parachondrium or open up the parachondrium, which is the lining around the ribs. We take out the rib itself so that we're freeing up the sternum, and then we do a little cut in the anterior sternum to get it to move forward. And then we move forward. We put a plate on to stabilize it, and they have new anatomy.

The advantage of that is the pectus anatomy compresses the heart and it limits the ability of the heart to fill and function. These people tend to be very, what we call rate dependent, they exercise and then they just hit a point where they can't. It's because that RV is so compressed that it can only beat so fast, and then they just can't produce any more energy. They can't do any work.

Again, an unusual experience here is that we do combined pectus surgery with heart surgery. And there's one key factor in their anatomy, is that once that sternum's back in normal position, it's completely floating. And so you can imagine if you did one compression on that sternum, what would happen?

Now, the challenge of this is you can imagine is this is this incredibly rare population and we all work time to compressions, time to perfusion, get on that chest and go fast. How do you get everyone to think, "Wait, is it this one in a billion chance and I should not do this that way?" It's a tough one to kind of ingrain in the system and not disrupt that immediate response that is totally correct 99.99% of the time otherwise.

So what do all these procedures have in common? Pain. And so the big issue here is when you're managing epidurals in these patients, now we don't use epidurals as much with the advent of intercostal cryoblation, but you'll deal with hypotension, epidurals cause a neurogenic shock, as we all know. And the typical response, the first step is to load the tank with a neurogenic shock, they need more fluid. And that's great if they're an esophagectomy. But what about if they're a pneumonectomy where they don't want fluid?

The key problem is if you drop the epidural when they're having pain, they sacrifice their pulmonary hygiene and their pressure is going up because you're giving them pain. They're actually... You're activating their endogenous fight or flight response.

And so how do you navigate that person is, again, going back and understanding their physiology and saying, esophagectomy easy. We're going to assess their pain. If their pain is well controlled, you can back off the epidural a little bit. If their pain is not well controlled, hit them with fluids. Backing off is an easy step to get their pressures up, but then you're going to be dealing two hours later with a patient with atelectasis, hypoxia and getting in trouble.

The pneumonectomies, on the other hand, can't give volume. So those you have to manage much more carefully. Go to pressors first, use phenyloephrine to counteract that neurogenic shock. But in the back of your mind, this is a very dry person, so we need to make sure that they're being perfused. And so the challenge there is if you've got a pneumonectomy whose pain, again, if their pain's controlled, well back off the epidural. If you have a pneumonectomy who has bad pain control and they're getting hypotensive, it's one, make sure they're not bleeding and all that stuff. But if you think it's the neurogenic shock, it's that balance between giving the fluid and using pressors. And what's your indicator that you're doing fine? They're making urine. They're telling you that they're maintaining their perfusion. If they're on a phenyloephrine drip with an epidural, the urine output needs to be followed exquisitely because that's the indicator that we're pushing them over the edge, and it's challenging to deal with. And then you can follow lactates too with those.

But that's the trick, and it's often the knee-jerk reaction is turn the epidural down, the thoracoplasty's chest wall resections, you can challenge with fluid. Generally, they're fine to challenge with fluid, but the first response should be challenge with fluid unless it's a pneumonectomy, and then you got to talk to the faculty, kind of bring everyone together and say, "What plan are we going to do to move forward?" But be cautious about just dropping that epidural off because you'll get into bigger trouble.

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