Gestione del paziente
sottoposto a chirurgia
combinata toracica ed
addominale
Dr CATTARUZZA
Dr 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
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 severo
FEV1 58% MEF25-75 17% DLCO non alterato
• EGA
pH
7.42
pCO2
42 mmHg
pO2
86 mmHg
P/F
410 mmHg
HCO3
27 mmol/l
BE
2.9 mmol/l
Hb
13.6 gr/dL
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
• Vis. Pneumologica: Dispnea Multifattoriale
10/12 (versamento/anemizzazione) Claritromicina 1 cp/die per due giorni
12/12
• DIMISSIONE
CASO CLINICO
16/12
17/12
• UO Medicina Generale GORIZIA
• DISPNEA+VERSAMENTO PLEURICO ndd
• 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
CONS. CARDIOLOGICA:
Fibrillazione atriale
Digossina + Ramipril + Bisoprololo
INSUFFICIENZA RESPIRATORIA
DETERIORAMENTO NEUROLOGICO
pH
7.30
pCO2
74 mmHg
pO2
79 mmHg
P/F
197 mmHg
HCO3
36 mmol/l
Lac
1.3 mmol/l
BE
14.3
mmol/l
CASO CLINICO
26/12
28/12
29/12
31/12
• NIV -> IOT
pH
7.25
pCO2
96 mmHg
pO2
90 mmHg
P/F
186 mmHg
HCO3
35 mmol/l
BE
14 mmol/l
• RADIOLOGIA INTERVENTISTICA
Posizionamento drenaggio ascesso epatico
• AUTOESTUBAZIONE + RIMOZIONE ACCIDENTALE DRENAGGIO EPATICO
• TRASFERIMENTO CLINICA CHIRURGICA
Hb
12,3gr/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. PNEUMOLOGICA
Drenaggio posteriore emitorace dx in aspirazione + Lavaggi cavo pleurico con
Urokinasi
10/01
• RX TORACE
Persiste velatura terzo medio inferiore CP dx
• TAC TORACO ADDOME
14/01 Lieve riduzione falda versamento pleurico dx, invariato quadro epatico
CASO CLINICO
15/01
16/01
EGA
• CONSULENZA PNEUMOLOGICA
Camere di aspirazione non rifornite
Trattamento chirurgico Revisione cavo pleurico dx +/- decorticazione
• CONSULENZA ANESTESIOLOGICA
METS<4 ASA III-IV
pH
7.47
pCO2
59 mmHg
pO2
99 mmHg
P/F
353 mmHg
HCO3
40 mmol/l
Lac
0.8 mmol/l
FiO2 0.28
17/01
• TRASFERIMENTO BLOCCO OPERATORIO CHIRURGIA TORACICA
BE
18 mmol/l
TOILETTE CAVO PLEURICO + DECORTICAZIONE PARZIALE IN TORACOTOMIA POSTERO
LATERALE
S
N
D
X
1
2
3
4
• DLT: tube exchange with ETT through AEC under directed
laryngoscopic view
• DLT cuff deflated withdrawn
EXTUBATIONto the 19-20 cm mark
 EDEMA
 AIRWAY
• ETT/BB: Remove
BBMUCOSA BLEEDING
 SECRETIONS
• Extubation with AEC
“..at the end of surgery, airways cannot be considered the same as before surgery and
intubation. “
MINERVA ANESTESIOL 2009;75:59-96
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 organisation
4-Patient related RF
 Good clinical sense/risk benefit analysis for IHT
 AE incidence remains high
 Inexperienced team/unstable patient is a risky combination
Fanara et al. Critical Care 2010, 14:R87
LAPAROTOMIA ESPLORATIVA TRANCE RESEZIONE EPATICA/TOILETTE LOCALE
TERAPIA INTENSIVA
2.5
2.5
2.5
2.5
2.5
CONSULENZA CARDIOLOGICA




FA PERMANENTE
SINDROME BRADICARDIA-TACHICARDIA
IPERTENSIONE ARTERIOSA
TEOFILLINA
* PREVEDERE IMPIANTO STIMOLAZIONE ENDOCARDICA
PROVVISORIO/DEFINITIVO
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:
Auroy - Anesthesiology 1997:
• 170,000 estimated epidurals
• “Severe complications” incidence:
0.52/10,000
• (9 complications)
• 30,413 epidurals
• 6 neurologic events  2/10,000
• paraesthesia or pain in all cases of
damage
Auroy - Anesthesiology 2002 :
Moen - Anesthesiology 2004:
• 5,561 non-obstetric epidurals
• 2 “Seriuous complications” (1 seizure,
1 meningitis)
• 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
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
British Journal of Anesthesia 102(2);179-90 (2009)
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
 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
 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
NAUSE/VOMITING
PRURITUS
SEDATION
RESPIRATORY DEPRESSION
HYPOTENSION
PRURITUS
HYPOTENSION
MOTOR BLOCKADE
NAUSEA/VOMITING
MOTOR BLOCKADE
SEDATION
RESPIRATORY DEPRESSION
Anesthesiology, V 115 • No 1
80 Patients
VAS at Rest
VAS Dynamic
Anesthesiology 2011; 115:181–8
52 Patients
Ropivacaine 0.2% vs Levobupivacaine 0.125% +/- Sufentanil 1mcg/mL
VAS rest and coughing, side effects and rescue PCA (within 48h)
1.
2.
3.
Similar static and dynamic analgesia
NO motor block – No major side effects
Similar incidende of minor side effects
European Journal of Anaesthesiology 2008; 25: 1020–1025
28 Patients Undergoing Abdominal Aortic Surgery
Elastomero (10mL/h)Ropivacaine 0.2%/Fentanyl 4mcg/mL
VS Levobupivacaine 0.125% /Fentanyl 4mcg/mL
Minimal differences in CardioRespiratory Parameters
Similar Antalgic Effect
Higher Anesthetic effect of Levobupivacain (Lower dosage)
Minerva Anestesiologica 2003;69:751-64
109 Patients Undergoing Major Abdominal
Surgery (TEA T9-T11)
4 Groups
(R, R+S0.5, R+S0.75, R+S1)
R0.2%+SO.75mcg/mL
appropriate
analgesia/side effects
Anesth Analg 2000;90:649 –57
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
Reduced risk of
postoperative
mortality
Adverse Effects:
Hypotension
Prutitus
Motor Blockade
Beneficial effect
:
Cardiovascular
pulmonary and
GI function
Neurologic
Complications:
Ematoma
Infections
Trauma
Annals of Surgery Volume 00, Number 00, 2013
CASO CLINICO
25/01
28/01
• Progressivo peggioramento scambi respiratori
• Non risposta a CICLI di NIV -> IOT
• 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