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Averting postpneumonectomy pulmonary edema. ('Preemptive' Steroid Dose).

SAN DIEGO -- Intraoperative administration of 250 mg of methyiprednisolone sodium succinate 5 minutes prior to the ligation of the pulmonary artery at the time of pneumonectomy may reduce the incidence of postpneumonectomy pulmonary edema and! or adult respiratory distress syndrome.

The drug may also decrease major complications such as pneumonia and thereby shorten hospital stay, Dr. Robert Cerfolio reported at the annual meeting of the Society of Thoracic Surgeons.

Although the idea of decreasing inflammatory response after reperfusion injury has been previously described, this is the first study that applies this principle to postpneumonectomy pulmonary edema (PPE), said Dr. Cerfolio, chief of thoracic surgery at the University of Alabama, Birmingham. "Since the precise pathophysiology of PPE remains unclear, prevention is difficult to do," he said. "We postulated that since PPE is a pulmonary capillary injury, perhaps a preemptive, suprapharmacologic dose of steroids might be beneficial."

In a study intended as a safety trial, Dr. Cerfolio and his associates collected prospective data from 52 men and 20 women who underwent elective pneumonectomies. Patients were divided into two groups: those who had surgery between Sept. 1, 1996, and Nov. 30, 1999, and those who had surgery between Dec. 1, 1999, and Oct. 31, 2002. The average age of the patients was 55 years.

The 37 patients in group 1 did not receive intraoperative steroids. The 35 patients in group 2 received 250 mg of methyiprednisolone sodium succinate intraoperatively 5 minutes prior to ligating the pulmonary artery

Dr. Cerfolio performed all operations. He said that he arrived at the choice dose of 250 mg methyiprednisolone sodium succinate by "just a guess."

All patients were extubated in the operating room and went to the intensive care unit where they received 0.6 cc/kg per hour of D5LR. Identical computerized order sets for both groups were used to help guide the postoperative management. Patients in both groups received the same type and dose of intravenous calcium channel blockers immediately postoperatively to help decrease the incidence of arrhythmias.

There were no significant differences in the preoperative factors between the two groups. But postoperatively a statistically significant advantage favored group 2 for the incidence of PPE and/or adult respiratory distress syndrome (0% vs. 13.5% in group 1), overall complications such as pneumonia but not including arrhythmias (20% vs. 43% in group 1), and for length of stay (6.1 days vs. 11.9 days in group 1).

In addition, there were no bronchopleural fistulas in group 2, compared with two (both right-sided) in group 1.

Dr. Cerfolio noted that the study was flawed because it was not randomized and the two groups underwent operations over two different time periods. "There could be some unknown difference between the two groups that we failed to recognize, and the first group was done sooner, so we were less experienced [with the procedure]," he said.

Dr. Keith Naunheim, the invited discussant of the paper, said that although the findings seem to set the stage for a subsequent, prospective, randomized trial, the study's use of historical controls provides "far less than definitive evidence."

A "learning-curve phenomenon applies to everyone involved in the care situations and may lead to significant differences in outcome not attributable to treatment variables alone," said Dr. Naunheim, chief of cardiothoracic surgery at St. Louis University.

The incidence of PPE is 5%-10% Although relatively uncommon, it can be fatal in up to 80% of patients.
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Author:Brunk, Doug
Publication:Internal Medicine News
Date:Mar 15, 2003
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