Pathology on the lesion showed non-small cell carcinoma with negative lymph nodes

The patient underwent a mediastinoscopy and bronchoscopy. In the recovery room, she developed immediate respiratory distress secondary to tracheal compression and deviation, with blood coming from the wound. She was taken back to the operating room emergently and was explored via a median sternotomy. A large hematoma was evacuated. She was found to have a bleeding small bronchial vessel. Her estimated blood loss was 2,000 mL, and she received 5 U packed RBCs, 6 U platelets, and 7 L crystalloid. She also had a left upper lobectomy at this time, as the mediastinoscopy biopsy findings were negative. Pathology on the lesion showed non-small cell carcinoma with negative lymph nodes.

Postoperatively, the patient developed a worsening acidosis and hypotension despite the use of vasoactive agents (ie, norepinephrine bitartrate, milrinone lactate, epinephrine, dobutamine hydrochloride, and maximal volume resuscitation) Cialis pills Australia. Her cardiac index ranged from 1.3 to 2.1 L/min/m2, with pulmonary artery BPs of 44/24 mm Hg and a wedge pressure of 16 to 18 mm Hg. The patient was maximally sedated with fentanyl and was paralyzed with vecuronium. Her chest radiograph showed the endotracheal tube position 3 cm above the carina, and no evidence of pneumothorax or other abnormality. A cardiac workup, including both a transthoracic and transesophageal echocardiogram, revealed no evidence of tamponade or focal wall motion abnormalities. Peripheral Doppler echocardiography examination showed no evidence of deep venous thrombosis. There were no sites of ongoing hemorrhage identified. There was no change in her troponin levels or ECG to indicate acute ischemia.

Arterial blood gas levels obtained with tidal volume of 550 mL, positive end-expiratory pressure (PEEP) of 5 cm H2O, 50% oxygen, and volume control ventilation at 15 breaths/min were as follows: pH, 7.26; Paco2, 37 mm Hg; Pao2, 135 mm Hg; and Paco2, 16 mm Hg. The patient’s peak airway pressure was 58 cm H2O, and her arterial lactate level was 8.0 mEq/L. The ventilator was changed to a pressure control mode for fear of causing bronchial stump blowout because of increasing airway pressures. The next set of arterial blood gas levels, obtained with settings of pressure control at 35 mm, a respiratory rate of 15 breaths/min, a tidal volume of 440 mL, and a fraction of inspired oxygen of 50% oxygen with PEEP set at 3 cm H2O, but auto-PEEP set to 11 cm H2O, were as follows: pH, 7.02; Paco2, 62 mm Hg; Pao2, 93 mm Hg.