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
Top Related