Cardiac Herniation

Cardiac herniation • An emergency and life threatening with mortality 50% • With pneumonectomy, in the 1st few hrs or few days later • Pathophysiology: o twisting of the SVC (SVC syndrome), o twisting IVC (cardiovascular collapse), o twisting distal trachea (wheezing), o twisting pulmonary veins (pulmonary edema), o pericardial constriction of the heart (myocardial ischemia and ventricular arrhythmia) • Risks: o Events that ↑ intrapleural pressure in the (ventilated) hemithorax or that ↓ intrapleural pressure in the surgical (empty) hemithorax may predispose the patient to cardiac herniation. o Placing the patient with the empty hemithorax in a dependent

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o Use of high levels of pressure and volume during mechanical ventilation of the remaining lung can push the heart into the empty hemithorax. And coughing o inadvertently applying suction to a chest drain in the empty hemithorax can pull the heart through a pericardial defect (tension vacuthorax). Management: o Immediate re-exploration → call the surgeon Stat o Place the Pt with the empty hemithorax up o D/C PEEP, vent with low pressure and Vt o D/C suction in the chest tube and inject 1-2 L of air in the empty hemithorax o Inotrops