Stenosi valvolare aortica e - anestesia triveneto · Favarel-Garrigues 1996, A&A77 60 >70 BI 0.5 %...
Transcript of Stenosi valvolare aortica e - anestesia triveneto · Favarel-Garrigues 1996, A&A77 60 >70 BI 0.5 %...
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Stenosi valvolare aortica e implicazioni con l’anestesia
loco-regionale
Dr.ssa Tripi, Dr. Dottore
Dr.ssa Parisella, Dr.ssa Glazar
Università degli Studi di Udine
Clinica di Anestesia e Rianimazione
Dir.: Prof. G. Della Rocca
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• Caso clinico
• Definizione/anestesia e SA
discussione• Tecniche anestesiologiche (AG vs ALR)
discussione• Conclusioni
AGENDA
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• Caso clinico
• Definizione/fisiopatologia SA
discussione• Tecniche anestesiologiche (AG vs ALR)
discussione• Conclusioni
AGENDA
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Paziente, F, 82 anni, ricoverata il 27/09/2016 perfrattura basicervicale femore destro a seguito dicaduta accidentale
Peso 70 kg, altezza 160 cm
In attesa di endoprotesi non cementata anca destra
CASO CLINICO
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Anamnesi:
Ipertensione arteriosa
Osteoporosi
Pregressi interventi: colecistectomia (AG) easportazione cisti mammaria (AL). Nonproblematiche anestesiologiche
Terapia: ramipril, calcio, profilassi TVP conenoxaparina 4000 U.I. 1x/die (ore 20)
Allergia ai cerotti (eritema cutaneo)
CASO CLINICO
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• Esame obiettivo:
Paziente vigile, orientata e collaborante. MVnormotrasmesso ad entrambi i campi polmonari, nonrumori patologici aggiunti. Attività cardiaca ritmica, soffiosistolico a diamante 3/6 sul focolaio aortico.
• Nega angor e dispnea, METs >4
• Vie aeree: Mallampati 3, DII> 3.5 cm e DTM> 6 cm , collo tozzo. Protesi mobili superiori e inferiori
CASO CLINICO
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• Rx torace (26/09/16): Non evidenti lesionipleuroparenchimali in atto nei campi visibili. Strie opachedisteletasiche epifreniche. Cardiomediastino nei limiti.Calcificazioni parietali aortiche. Scf liberi.
• Esami ematochimici: Hb 13.4x103/µL, PLT 207000/µL, INR1.44, aPTT 0.99, Cr 0.69 mg/dL, BNP 70 pg/mL
• ECG: RS con BAV I grado. Possibile infarto inferiore,probabilmente pregresso con estensione posteriore.
• Mai eseguita visita cardiologica in passato
CASO CLINICO
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VALUTAZIONE ANESTESIOLOGICA PREOPERATORIA
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VALUTAZIONE ANESTESIOLOGICA PREOPERATORIA
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VALUTAZIONE ANESTESIOLOGICA PREOPERATORIA
★
★
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Dubbio clinico: quale tipo di anestesia scegliere?
• AG?
• AS?
SI ACQUISISCE CONSENSO INFORMATO PER AG
NULLA OSTA anestesiologico
CASO CLINICO
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• Fentanyl 50 mcg prima della mobilizzazione
10:50 Arrivo nel blocco operatorio
• AP 175/90mmHg, HR 93 bpm, SpO2 94%in a.a.
• Midazolam 3 mg totali
• Maschera Venturi FiO2 0.4 SpO2 98%
• Inacannulamento arteria radiale dx.
11:00 Arrivo in presala
CASO CLINICO
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• Propofol 80+20 mg, fentanyl 150 mcg, rocuronio 35 mg
• AP 105/60 mmHg, HR 65 bpm, SpO2
100%
11:35 Induzione
dell’anestesia
• Laringoscopia diretta, MAC-4
• Tubo endotracheale 7.0, fissato a 21 cm alla rima labiale
11:40 IOT
CASO CLINICO
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• Episodio di desaturazione con ipotensione: SpO2 85% con FiO2 0.4, AP 90/60 mmHg
• MV monolaterale, no rumori patologici aggiunti, si ritira tubo endotracheale di 1 cm
• Ripresa della ventilazione, si somministra fenilefrina 0.1 mg: SpO2 98%, AP 115/65 mmHg
11:45
Posizionamento paziente
CASO CLINICO
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150 (residua) 100 (250)
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Durante l’intervento altri 2 episodi di desaturazione con ipotensione
•Ritirato tubo endotracheale di 1 cm
•Ripresa della ventilazione
Eseguito EGA-A: pH 7.42, pO2
101, pCO2 36, SaO2 98.6%, P/F 356
13:00 episodio di ipotensione (AP 90/55 mmHg, HR 93 bpm) secondario a sanguinamento intraoperatorio (400 mL)trattato con albuminata 4% 250 mL
• Stabilizzazione dell’emodinamica (AP 110/60 mmHg, HR 72 bpm)
CASO CLINICO
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Elastomero 2 mL/h e.v. con sufentanil 5 mcg/h
4 twitch al TOF, T.R.>0.9
13:20 fine intervento
13:35 Paziente difficilmente risvegliabile, si somministra flumazenil 0.2 mg
13:40 Estubazione
Posizionamento maschera Venturi FiO2 0.4: AP 145/85 mmHg, SpO2 93%
CASO CLINICO
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• deconnesso elastomero13:45 paziente soporosa ma
facilmente risvegliabile
• pH 7.34, pO2 65, pCO2 42, SaO2
94.8%, P/F 16814:05 EGA-A
• pH 7.38, pO2 76, pCO2 36, SaO2
97.4%, P/F 19014:45 EGA-A
15:25 Trasferimento in T.I. per insufficienza respiratoria
CASO CLINICO
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15:30 Arrivo in terapia intensiva
15:35 Pz vigile, collaborante, in
RS con maschera venturi FiO2 0.4, SpO2 97%, P/F 198, AP 150/85
mmHg
16:20 Ecotorace ed ecocardio:
linee B ai campi polmonari
medio basali bilaterali
17:00 Ciclo NIV; P/F 252
22:00 Ciclo NIV; P/F 288
CASO CLINICO
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CASO CLINICO
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CASO CLINICO
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Terapia intensiva 29/11
12:30 Pz sveglia, vigile e collaborante, in terapia analgesica con ossicodone/naloxone. In RS con maschera venturi FiO2 0.4, P/F 233. Emodinamica stabile, non supporto aminico, AP 120/80 mmHg, HR 90 bpm
16:00 Trasferimento nel reparto di Traumatologia
CASO CLINICO
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Durante la degenza in Traumatologia non più problematiche di tipo respiratorio o emodinamico. Alla dimissione AP 140/80 mmHg, HR 72 bpm, SpO2 97% in
AA
13/10 dimissione dall’ospedale
CASO CLINICO
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• Caso clinico
• Definizione/fisiopatologia SA
discussione• Tecniche anestesiologiche (AG vs ALR)
discussione• Conclusioni
AGENDA
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DEFINIZIONE
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• Caso clinico
• Definizione/fisiopatologia SA
discussione• Tecniche anestesiologiche (AG vs ALR)
discussione• Conclusioni
AGENDA
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ANESTESIA E SA
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A.G. A.L.R.
TECNICHE DI ANESTESIA NEL PAZIENTE ORTOPEDICO
OUTCOME
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• Retrospective, propensity score-matched cohort study
• From 2003 to 2014
• THR/TKR
• 8.553 (79%) received Spinal anesthesia
• 2.315 (21%) received General anesthesia
• Effect of anesthetic technique on a 30 day-mortality
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Spinal anesthesia after elective TJR was associated with:
Lower incidence of death within 30 daysLower incidence of major blood lossShorter operating room procedure timeShorter hospital stay
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29 studies (1989-2015) involving 10.488 patients
Patient undergoing elective THA/TKA Outcome
• Type of anesthesia (general or neuraxial)
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A.G. A.L.R.
TECNICHE DI ANESTESIA NEL PAZIENTE CON SA
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★
★
★
★★
★
★
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62 patients with hip fracture and coexisting AS
100 hip fracture patients without AS (control group)
10-year period
Management and outcome of patients with AS
• Type of anesthesia (general, spinal or combined)
• Rate of major in-hospital complications
Rate in-hospital and 1-year mortality compared with controls
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Mean age of Aortic Stenosispatients was 85.9 + 7.4
1-year mortalityrate was similarin both groups
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From March 2001 to February 2005
272 hip fracture pts with a previously undiagnosed murmurand echocardiographically proven aortic stenosis
Control group of 3698 hip fracture pts without aorticstenosis
To observe influence of the echocardiographic findingsobtained on hip on subsequent anaesthetic and surgicalmanagement
To compare their 30-day and 1-year mortality rates withcontrol group
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‘Whenever possible the anaesthetist of a patient with aorticstenosis should obtain a pre-operative echocardiogram of theaortic valve’
• Use of invasive monitoring
• Intensive or high dependency care
• Excellent postoperative pain control for patients with aorticstenosis
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30 consecutive pts with severe asymptomatic AS underwentnoncardiac surgery
Compared to 60 age-matched and gender-matched pts withmild-to-moderate AS (controls)
Transthoracic echocardiograms available from 6 months beforethe surgery
Mean age of 78 + 9 years
The primary end point• composite of death, MI, heart failure, ventricular arrhythmias before
dismissal
• intraoperative hypotension requiring vasopressor administration
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• The composite end point in the pts (n 10; 33%) vs thecontrols (n 14; 23%)
– the difference was not statistically significant (p 0.06)
• Intraoperative hypotension requiring vasopressor use(O.R. 2.5, 95% CI, 0.8-7.6)
• No deaths or postoperative heart failure in pts undergoingnoncardiac surgery
• Intermediate-to-low–risk noncardiac surgery for pts withsevere asymptomatic AS can be performed relativelysafely
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• Retrospective case-controlled review
• From 2011 to 2015
• Moderate/severe AS
• Age ≥ 65 years
• 65 hip fracture cases and 129 controls
• Complications at 30 days and 1 year
mortality
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• Uomo, 48 aa con SA severa (AVA 0.8 cm2), asintomatico, classe NYHA 1
• Riduzione di frattura di anca
• BNP lombare (30 mL levobupi 0.25%) + sciatico (20 mLlevobupi 0.25%) + ileoipogastrico (10 mL levobupi 0.25%)
• Sedazione con 4 mg midazolam tot
• Monitoraggio IBP
• Lieve riduzione BP (140/80 122/78)
• No vasopressori
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• 87-yr-old, ♀, 50 kg, 151 cm; closed fracture right trochanter
• Senile dementia, multiple cerebral infarts, resected coloniccancer
• Severe aortic stenosis
• No known history of angina, syncope, congestive heart failure
Echocardiogram:
• Aortic valve area of 0.38 cm2
• Aortic valve pressure gradient 70 mmHg
ECG:
• Left ventricular hypertrophy.
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• Surgery time 90 min
• Output: blood lost 200 mL; urine 130 mL
• Input: SF 900 mL
• i.c. of phenylephrine at 2 μg/min to maintain blood pressure at 110-130/60-70 mmHg
• i.c. of bupivacaine 0.125% at 4–6 mL/h for 17 h
• Not complain of pain during surgery and not require rescue analgesics
• Discharged at home 15 days post-operative
RIGHT PARAVERTEBRAL LUMBAR PLEXUS BLOCK
Epidural catheter inserted for 4 cmRopivacaine 0.5% , total 15 ml
RIGHT SCIATIC NERVE BLOCKParasacral approach, 6 cm from PSIS; 100 mm needlePlantar flexion elicited 5 cm depth(0.5 mA) Ropivacaine 0.5% , total 10 ml
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• Caso clinico
• Definizione/fisiopatologia SA
discussione• Tecniche anestesiologiche (AG vs ALR)
discussione• Conclusioni
AGENDA
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In letteratura ci sono insufficienti evidenze per concludere se una
tecnica anestesiologica (AG vs ALR) influenzi di più la mortalità
nei pazienti in chirurgia ortopedica dell’anca e ginocchio;
Lieve evidenza di miglior outcome in termini di LOS,
complicanze polmonari e perdite ematiche con ALR
[ANESTHESIOLOGY 2016; 125:724-31, ANESTHESIOLOGY
2012; 117:72-92, JAMA 2014; 311(24):2508-2517, BJA
116(2):163-76(2016)]
CONCLUSIONI:ALR vs AG in hip/knee surgery
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Monitoraggio intraoperatorio per i pz con SA
(IBP, BIS, TEE… PAC, if indicated);
Vasopressori da tenere a disposizione:
• Noradrenalina
• Fenilefrina
• Adrenalina;
CONCLUSIONI:Anestesia e stenosi aortica (qualsiasi tecnica)
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ALR come alternativa per i pz con SAasintomatica;
Tecniche (ALR descritte in letteratura):
• Epidurale (sempre meno usata)
• Spinale continua (?)
• Blocco lombare + sciatico parasacrale
• Spinale single shot a basso dosaggio (e farmaciisobarici)
• Esperienza dei singoli anestesisti.
CONCLUSIONI:ALR e stenosi aortica
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Spinale single shot a basso dosaggio (e farmaci iso-ipobarici)
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4 mg Bupivacaine
+ 20 µg Fentayl
10 mg Bupivacaine P
Age (years) 85 + 8 82 + 5 -
Peak level of block
(pinprick)
T8 (T6-T10) T6 (T4-T8) < 0.01
Lowest/baseline systolic
pressure (median)
0.81 + 0.10 0.54 + 0.12 0.001
N° of pt treated for
hypotension
1/10 9/10 0.001
Total Efedrine (mg)
median
0.5 + 1.6 32 + 17 < 0.001
N° of pt requiring
phenylephrine after 50
mg ephedrine
0/10 2/10 -
Fluids (mL) 955 + 240 1150 + 337 -
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Ist AIM: Intraop AP and hypotension during General or
Spinal Anesthesia among 1131 non-consecutive patients
with hip fracture.
General Anesthesia for 489 patients (43.2%) produced a greater
mean (SD) fall in systolic blood pressure than Apinal Anesthesia for
578 patients (51.1%):
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Differenza se > 1.5 ml
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LETTERATURA ETA N° AL POSIZ CASI
(mg)
CTRL
(mg)
EVENTO P value
Bruce Ben David 2000,
Anesthesiology32
>70 20 BI 0.5 %
+20mcg F
Fianco
AF su4 10 vasopressore
ipotensione
= 0.05
C. Olofsson 2004,
Acta A. S.74
50 BI 0,5 %
+ 5mcg S
SedutaBIS
su7.5 15 vasopressore
ipotensione
< 0.001
Hoda MQ 2007, JPMA75 >65 60 Biso +20mcg F AF su 6/8 10 vasopressore
ipotensione
<0.05
Lilot M 2013, A&A76 68 R
+ 5mcg S
Fianco 15’ 6 8/10/12 ipotensione 0.0004
Favarel-Garrigues 1996, A&A77 60 >70 BI 0.5 % Fianco 45’ ASC
5-2.5
SD
10-15
vasopressore
ipotensione
<0.0001
Minville 2006, A&A78 >75 74 Biso ASC
2.5 rip
SD
7.5
ipotensione
severa ipot.
vasopressore
=0.005
<0.0001
=0.005
Tabella I. Dosaggi e confronti di anestesie spinali con tecnica single shot o in anestesia spinale continua. Leggenda: AL = anestetico locale, POSIZ = posizione del paziente, CTRL = controlli, EVENTO = evento emodinamico, BI=bupivacaina iperbarica, F=Fentanyl, S=Sufentanil, R=Ropivacaina, Biso=Bupivacaina isobarica, AF= arto fratturato, BIS= bisello, ASC=anestesia spinale continua, SD=singola dose, rip=ripetibili).