Trial Short Case 2 April 2022

Answers

Question 1

This patient has bilateral necrotising pneumonia from staph aureus on a background of COVID pneumonitis and myocarditis, critical illness and DKA.

He has developed a complex right pleural space

There is severe damage to most of his left lung

CT findings:

Large right hydropneumothorax

Mediastinal shift to the left, concerning for tension.

Multiple locules of gas within the fluid component and enhancement of the pleura, suggestive of empyema.

The presence of pleural gas raises concern for a bronchopleural fistula.

Associated near complete collapse of the right lung.

Extensive bilateral consolidation with cavitation is demonstrated.

X-ray series:

Progressive changes of lung parenchyma and pleural spaces.

Day 1 x ray shows –

Atelectasis/consolidation at the left base and small left pleural effusion. Possibly early consolidation right lung base. There is no significant right-sided effusion. There is no pneumothorax or free air under the diaphragm.

Day 15 x ray and subsequent xrays show –

Right hydropneumothorax with mediastinal shift

Some improvement of effusion with insertion of pigtail catheter, but residual collection and air indicating loculation

Additional chest drains placed to attempt control of space and infection with some re-expansion of lung and resolution of mediastinal shift

Pass

summarises details from vignette. Can identify relevant CT and x-ray findings. Discusses concern of bronchopleural fistula/ruptured lung abscesses

Strong pass

Delivers a succinct summary that includes relevant details from the vignette. Identifies that the DKA and COVID myocarditis are now largely managed/resolved, and focuses on respiratory issues and infection. Discusses cavitating lesion etiology of staph aureus and mentions other possible causes.

Identifies mediastinal shift and resolution from drainage.

Identifies the progression of lung disease throughout the series of images.

Question 2

Pass

Identifies low Hb and considers preop transfusion.

Identifies INR 1.9 and discusses correction.

Identifies need for appropriate cultures and specimens to be sent from theatre (micro and sensitivities).

Other discussion of appropriate preoperative medical management. Discusses plan with patient and family.

Ensures appropriate precautions taken for infectious patient in line with hospital policy.

Identifies likelihood of bronchopleural fistula

Strong pass

Shows forward thinking about ongoing management of patient

- Identifies and discusses the implications of the significant disease on the LEFT lung and the possibility of needing lung resection in the near future.

-perioperative pain management (pros and cons of epidural, paravertebral catheter)

-Intraoperative ventilation strategy - surgeon and anaesthetist work together.  can patient ventilate on left lung alone - ?double lumen tube, ?bronchial blocker (ventilate left lung and right upper lobe), ?intermittent ventilation

-Ensures intraop specimens adequate for ongoing management and to rule out differentials: ?TB cultures [patient has immigrated from India with higher rates of dormant TB] ?fungal cultures [patient has been critically unwell with reduced immune function secondary to new diagnosis of diabetes

Question 3

Pass

Describes an appropriate operation to decorticate lung, clean pleural space, identifiy BPF if present, resect necrotic lung if needed, leave drains in pleural space

Discusses and justifies operative approach (VATS/Open) – If VATS when would proceed to thoracotomy.

Strong pass

Considers muscle sparing incision (may need pedicle flap if BPF)

Makes an appropriate plan for identifying and controlling air leak in context of infection

Has management plan for sudden intraop desaturation