Gestione del paziente sottoposto a chirurgia combinata toracica ed addominale

Dr CATTARUZZADr CHIARANDINI, Dr.ssa POMPEI, Dr.ssa PRAVISANI

Università degli Studi di Udine

Scuola di Specializzazione in Anestesia, Rianimazione e Terapia Intensiva

Dir Prof. G. Della Rocca

CASO CLINICO

CASO CLINICO

pH7.42

pCO2

42 mmHg

pO2

86 mmHg

P/F410 mmHg

HCO3

27 mmol/l

BE 2.9 mmol/l

Hb13.6 gr/dL

22/11

• ECG: FA risp. Ventricolare lenta aspecifica asintomatica (TAO)

• ECOcardio: FE 60% PAPs 35 mmHg, Dilatazione Biatriale severa

• RX T: calcificazioni lobo superiore Sn

• RM: multiple lesioni focali solide al VII (57 mm) e IV (26mm) seg. Epatico

• PFR: Deficit ostruttivo severoFEV1 58% MEF25-75 17% DLCO non alterato

• EGA

CASO CLINICO

3/12

• Metastasectomia IV – VII segmento epatico

• Secondarismi da GIST

8/12• Discomfort respiratorio post operatorio

velatura pleurica Dx (RX) indici flogosi, febbricola

10/12• Vis. Pneumologica: Dispnea Multifattoriale

(versamento/anemizzazione) Claritromicina 1 cp/die per due giorni

12/12• DIMISSIONE

CASO CLINICO

16/12

• UO Medicina Generale GORIZIA

• DISPNEA+VERSAMENTO PLEURICO ndd

17/12• PIPERACILLINA/TAZOBACTAM MEROPENEM ( indici flogosi)

20/12

• DISPNEA SCADIMENTO CONDIZIONI GENERALI

• DRENAGGIO TORACICO DX

23/12

• TC t-a: EMPIEMA PLEURICO BASE DX+ ASCESSO SUBFRENICO

• (VII segmento 6.5 cm)

26/12• CLINICA CHIRUGIA GENERALE UDINE

CASO CLINICO

pH7.30

pCO2

74 mmHg

pO2

79 mmHg

P/F197 mmHg

HCO3

36 mmol/l

Lac1.3 mmol/l

BE14.3mmol/l

CONS. CARDIOLOGICA: Fibrillazione atriale Digossina + Ramipril + Bisoprololo

INSUFFICIENZA RESPIRATORIA DETERIORAMENTO NEUROLOGICO

CASO CLINICO

26/12• NIV -> IOT

28/12• RADIOLOGIA INTERVENTISTICA

Posizionamento drenaggio ascesso epatico

29/12• AUTOESTUBAZIONE + RIMOZIONE ACCIDENTALE DRENAGGIO EPATICO

31/12• TRASFERIMENTO CLINICA CHIRURGICA

pH7.25

pCO2

96 mmHg

pO2

90 mmHg

P/F186 mmHg

HCO3

35 mmol/l

BE 14 mmol/l

Hb12,3gr/dL

CASO CLINICO

31/12• TAC TORACO ADDOME Versamento

pleurico dx 6.5cm, raccolta trancia resezione VII seg. Epatico 7x6cm

3/01• RADIOLOGIA INTERVENTISTICA

Nuovo drenaggio raccolta epatica

6/01

• CONS. PNEUMOLOGICADrenaggio posteriore emitorace dx in aspirazione + Lavaggi cavo pleurico con Urokinasi

10/01• RX TORACE

Persiste velatura terzo medio inferiore CP dx

14/01

• TAC TORACO ADDOMELieve riduzione falda versamento pleurico dx, invariato quadro epatico

CASO CLINICO

15/01

• CONSULENZA PNEUMOLOGICACamere di aspirazione non riforniteTrattamento chirurgico Revisione cavo pleurico dx +/- decorticazione

16/01• CONSULENZA ANESTESIOLOGICA

METS<4 ASA III-IV

EGA

FiO2 0.28

17/01• TRASFERIMENTO BLOCCO OPERATORIO CHIRURGIA TORACICA

pH7.47

pCO2

59 mmHg

pO2

99 mmHg

P/F353 mmHg

HCO3

40 mmol/l

Lac0.8 mmol/l

BE18 mmol/l

TOILETTE CAVO PLEURICO + DECORTICAZIONE PARZIALE IN TORACOTOMIA POSTERO LATERALE

SN

DX

EXTUBATION

EDEMA AIRWAY MUCOSA BLEEDING SECRETIONS

“..at the end of surgery, airways cannot be considered the same as before surgery and intubation. “

MINERVA ANESTESIOL 2009;75:59-96

1

• DLT: tube exchange with ETT through AEC under directedlaryngoscopic view

2• DLT cuff deflated withdrawn to the 19-20 cm mark

3• ETT/BB: Remove BB

4• Extubation with AEC

Fanara et al. Critical Care 2010, 14:R87

10 years REVIEW IHT and Related Adverse Effects (AE)

1-Equipment Related Risk Factors (RF)2-RF related to the transport team (Experience)3-RF relating to transport indication and organisation4-Patient related RF

Good clinical sense/risk benefit analysis for IHT AE incidence remains high Inexperienced team/unstable patient is a risky combination

LAPAROTOMIA ESPLORATIVA TRANCE RESEZIONE EPATICA/TOILETTE LOCALE

TERAPIA INTENSIVA

CONSULENZA CARDIOLOGICA

FA PERMANENTE SINDROME BRADICARDIA-TACHICARDIA IPERTENSIONE ARTERIOSA TEOFILLINA

* PREVEDERE IMPIANTO STIMOLAZIONE ENDOCARDICA PROVVISORIO/DEFINITIVO

2.5 2.5 2.5 2.5 2.5 2.5

AGENDA

TEA risk and benefits

TEA awake or asleep?

TEA solutions administered

TEA outcome

Anesthesiology 2011; 115:181–8

Anesthesiology Research and Practice Volume 2012, Article ID 309219

Anesthesiology Research and Practice Volume 2012, Article ID 309219

Aromaa - Acta An Scand 1997:

• 170,000 estimated epidurals

• “Severe complications” incidence: 0.52/10,000

• (9 complications)

Auroy - Anesthesiology 1997:

• 30,413 epidurals

• 6 neurologic events 2/10,000

• paraesthesia or pain in all cases of damage

Auroy - Anesthesiology 2002 :

• 5,561 non-obstetric epidurals

• 2 “Seriuous complications” (1 seizure, 1 meningitis)

Moen - Anesthesiology 2004:

• 450,000 estimated epidurals

• “Severe neurological complications”: 1:3,600 non-obst epidurals

Horlocker

Epidurals under AG

4,298 lumbar epidurals

No neurologic complications

Confidence interval 95%: serious neurologic

complications up to 0.08%

Anesth Analg 2003;96:1547–52

British Journal of Anesthesia 102(2);179-90 (2009)

97,925 PERIOPERATIVE epidurals

Permanent injury in adult periop

epidural:

pessimistic: 17.4/100,000

optimistic: 8.2/100,000

Paraplegia + death in adult periop

epidural:

pessimistic: 6.1/100,000 optimistic: 1.0/100,000

Awake patient

Deep breathing expand the potential cavity of the epidural space

Better setting for catheterization

Positive pressure ventilation ↓epidural space

Difficult epidural catheter insertion

There is still substantial controversy

many anesthesia providers believe that epidural catheters should be placed in awake or

mildly sedated patients capable of providing feedback

THORACIC EPIDURAL PLACEMENT should never be attempted on an anesthetized patient

Complication is rare, yet catastrophic

Is inevitable that needles or catheters will inadvertently violate the cord, but in some cases injury might be

minimized by a responsive patient

SEDATION

RESPIRATORY DEPRESSION

NAUSEA/VOMITING

PRURITUS

HYPOTENSION

MOTOR BLOCKADEMOTOR BLOCKADE

HYPOTENSION

NAUSE/VOMITING

PRURITUS

SEDATION

RESPIRATORY DEPRESSION

Anesthesiology, V 115 • No 1

Anesthesiology 2011; 115:181–8

VAS DynamicVAS at Rest

80 Patients

European Journal of Anaesthesiology 2008; 25: 1020–1025

52 Patients

Ropivacaine 0.2% vs Levobupivacaine 0.125% +/- Sufentanil 1mcg/mLVAS rest and coughing, side effects and rescue PCA (within 48h)

1. Similar static and dynamic analgesia2. NO motor block – No major side effects3. Similar incidende of minor side effects

Minerva Anestesiologica 2003;69:751-64

28 Patients Undergoing Abdominal Aortic Surgery

Elastomero (10mL/h)Ropivacaine 0.2%/Fentanyl 4mcg/mLVS Levobupivacaine 0.125% /Fentanyl 4mcg/mLMinimal differences in CardioRespiratory ParametersSimilar Antalgic EffectHigher Anesthetic effect of Levobupivacain (Lower dosage)

Anesth Analg 2000;90:649 –57

109 Patients Undergoing Major AbdominalSurgery (TEA T9-T11)

4 Groups(R, R+S0.5, R+S0.75, R+S1)

R0.2%+SO.75mcg/mLappropriate

analgesia/side effects

Anesthesiology 2002; 96:536 – 41

…..

Randomized controlled trials:

Epidural vs Systemic Analgesia (1971-2011)

Different type of Surgery 4525 epidurals Mortality, morbidity and

epidural related adverse effects

Annals of Surgery Volume 00, Number 00, 2013

…..

Annals of Surgery Volume 00, Number 00, 2013

Annals of Surgery Volume 00, Number 00, 2013

Annals of Surgery Volume 00, Number 00, 2013

Reduced risk of postoperative

mortality

Beneficial effect:

Cardiovascularpulmonary and

GI function

Adverse Effects:

Hypotension Prutitus

Motor Blockade

NeurologicComplications:

Ematoma Infections

Trauma

CASO CLINICO

25/01

• Progressivo peggioramento scambi respiratori

• Non risposta a CICLI di NIV -> IOT

28/01• Confezionamento TRASCHEOSTOMIA -> Weaning respiratorio (T-tube)

• Rimozione drenaggi Toracici

10/02

• IPERTENSIONE in Terapia Farmacologica

• FIBRILLAZIONE ATRIALE (HR 100bpm)

12/02

• Condizioni cliniche stabili (Tracheo in RS,FiO2 0.28 P/F>300, Fac-HTN)

• Terapia: Enoxaparina – Spironolattone – Ramipril - Teofillina

13/02• TRASFERIMENTO presso Terapia Intesiva di Monfalcone