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

pCO 2

42 mmHg

pO 2

86 mmHg

P/F

410 mmHg

HCO 3

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

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 CONS. CARDIOLOGICA:

Fibrillazione atriale Digossina + Ramipril + Bisoprololo INSUFFICIENZA RESPIRATORIA DETERIORAMENTO NEUROLOGICO

pH

7.30

pCO 2

74

mmHg pO 2

79 mmHg

P/F

197 mmHg

HCO 3

36 mmol/l

Lac

1.3 mmol/l

BE

14.3

mmol/l

CASO CLINICO

26/12

•

NIV -> IOT pH

7.25

pCO 2

96 mmHg

pO 2

90 mmHg

P/F

186 mmHg

HCO 3

35 mmol/l

BE

14 mmol/l

Hb

12,3 gr/dL

28/12

•

RADIOLOGIA INTERVENTISTICA

Posizionamento drenaggio ascesso epatico

29/12

•

AUTOESTUBAZIONE + RIMOZIONE ACCIDENTALE DRENAGGIO EPATICO

31/12

•

TRASFERIMENTO CLINICA CHIRURGICA

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

14/01 •

TAC TORACO ADDOME

Lieve riduzione falda versamento pleurico dx, invariato quadro epatico

CASO CLINICO

15/01

•

CONSULENZA PNEUMOLOGICA

Camere di aspirazione non rifornite

Trattamento chirurgico Revisione cavo pleurico dx +/- decorticazione

16/01

•

CONSULENZA ANESTESIOLOGICA METS<4 ASA III-IV EGA FiO 2 0.28

pH

7.47

pCO 2

59 mmHg

pO 2

99 mmHg

P/F

353 mmHg

HCO 3

40 mmol/l

Lac

0.8 mmol/l

BE

18 mmol/l

17/01

•

TRASFERIMENTO BLOCCO OPERATORIO CHIRURGIA TORACICA

TOILETTE CAVO PLEURICO + DECORTICAZIONE PARZIALE IN TORACOTOMIA POSTERO LATERALE

S N D X

1 • DLT: tube exchange with ETT through AEC under directed laryngoscopic view 2 3   EDEMA AIRWAY MUCOSA BLEEDING SECRETIONS • Extubation with AEC 4 “..at the end of surgery,

airways cannot be considered the same as before surgery

intubation. “ and 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

2.5

CONSULENZA CARDIOLOGICA     FA PERMANENTE SINDROME BRADICARDIA-TACHICARDIA IPERTENSIONE ARTERIOSA TEOFILLINA * PREVEDERE IMPIANTO STIMOLAZIONE ENDOCARDICA PROVVISORIO/DEFINITIVO

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

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

 HYPOTENSION  MOTOR BLOCKADE  NAUSE/VOMITING  PRURITUS  SEDATION  RESPIRATORY DEPRESSION   HYPOTENSION MOTOR BLOCKADE  NAUSEA/VOMITING  PRURITUS  SEDATION  RESPIRATORY DEPRESSION Anesthesiology, V 115 • No 1

VAS at Rest

80 Patients

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 Beneficial effect : Cardiovascular pulmonary and GI function Adverse Effects: Hypotension Prutitus Motor Blockade Neurologic Complications: Ematoma Infections Trauma

Annals of Surgery Volume 00, Number 00, 2013

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