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Traumatic Pneumonectomy: A Viable Option for Patients in Extremis

The combination of respiratory insufficiency, right heart failure, and depth of shock is thought to result in mortality approaching 100 per cent after pneumonectomy. We did a retrospective review of patients requiring pneumonectomy over 6 years. Data collected included demographics, emergency department and operating room course, critical care management, complications, and mortality. Seven patients were identified. Mean age was 26.5 years. Five sustained penetrating and two sustained blunt trauma. Mean Injury Severity Score was 26 and Revised Trauma Score was 4.4. Mean admission systolic blood pressure, lactate, and pH were 98 mm Hg, 10.1 mmol/L, and 6.98, respectively. Mean time to operation was 49 minutes. Mean estimated blood loss was 5.4 liters and mean intraoperative transfusion was 13.1 units of packed red blood cells. All seven developed right heart failure. Four required prone ventilation, one oscillating ventilation, four continuous renal replacement, and three extracorporeal membrane oxygenation. Four patients died (57%); two of refractory right heart failure within the first 24 hours and two of multiple organ failure on postoperative days 9 and 138. Mean length of stay in survivors was 71 days. All survivors were neurologically intact and none required mechanical ventilation at discharge. The need for pneumonectomy after trauma is rare. Patients undergoing pneumonectomy who present in extremis require significant intra and postoperative support, with a survival of 42 per cent.