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Preoperative Evaluation/Patient Issues/Should a patient with a recent pneumothorax have surgery in an ASC?

QUESTION:

A 28 y/o male is status/post MVA 14 days ago. He was treated then for pneumothorax. How long after a pneumothorax should an elective procedure be done? (I have polled anesthesiologists and thoracic surgeons at my old home (Mass General), and folks here in Phoenix. The consensus seems to be three weeks.)

-- From Joshua A. Bloomstone, M.D., Phoenix, AZ

REPLY:

The chest surgeons at our institution feel that one should wait 4 to 6 weeks before exposing a patient to a general anesthetic. Their rationale is that it takes at least four weeks for the lung and pleura to fully heal.

-- From Grover R. Mims, M.D., Winston-Salem, N.C.

REPLY:

Elective surgical procedures can be performed once the pneumothorax is resolving (i.e., the lung is healing).  If the chest tube drainage is minimal and there are no bubbles, the hole in the lung should be healing and positive pressure ventilation should not reopen it.  One does not have to wait until the pneumothorax is completely gone.  In our hospital (a major trauma center), chest tubes are commonly removed (once the criteria for removal are achieved) while the patients are still on positive pressure ventilation in the ICU. This suggests that ventilation during anesthesia should not be deleterious.  Of course, we should have a high index of suspicion in case problems do occur intraoperatively.

As well, the patient's clinical status plays a major role in the decision making. The patient should be maintaining saturation and not in respiratory distress. A case I had today illustrates some of these points:

A 17 year old with a pelvic fracture 2 days ago was scheduled for repair of the fracture.  On admission after the MVC, the chest X-ray showed some fluid and a pneumothorax.  However, as the patient was comfortable, with no signs of distress and the pneumothorax was small, no chest drain was placed.   Now that the patient was going to have to be ventilated during surgery, there were discussions as to whether we should place a chest tube prophylactically.  However, we decided not to place one and just observe the patient closely, as the pneumothorax was resolving, suggesting that the lung injury was healing.  No problems were experienced intraoperatively.

A chest X-ray on the morning of surgery is also recommended, as illustrated by another case I had today:

A patient with secondaries in the lung was scheduled for brain tumor resection   A lung biopsy was done 10 days ago, after which a chest tube was placed.  The chest tube was removed 3 days ago.  A chest X-ray this morning showed that the pneuothorax had reaccumulated.  Thus, we decided to place a chest tube after the induction of general anesthesia.

-- From Girish Joshi, M.D., Dallas, TX

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