Post Operative Management

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Post Operative Management

  1. 1. PULMONARY ENDARTERECTOMY: POST-OPERATIVE MANAGEMENT F. MOJOLI Cattedra di Anestesiologia e Rianimazione Università degli Studi di Pavia Servizio di Anestesia e Rianimazione I IRCCS Policlinico San Matteo - Pavia
  2. 2. POSTOPERATIVE MANAGEMENT <ul><li>Weaning from M echanical V entilation </li></ul><ul><li>Weaning from I notropes, V asopressors and P ulmonary V asodilators </li></ul><ul><li>Effective A nticoagulation </li></ul><ul><li>Management of C omplications </li></ul>
  3. 3. RESPIRATORY CHANGES AFTER PEA <ul><li>Anesthesia Sternotomy CPB Bed Rest </li></ul>Hypoventilation of DEPENDENT pulmonary regions Hyperperfusion of DEPENDENT pulmonary regions Pulmonary Artery Steal PEA V’ / Q mismatch Postoperative Hypoxemia Functional Residual Capacity decrease Atelectasis formation ExtraVascular Lung Water increase Pulmonary Compliance decrease
  4. 4. Post PEA Mechanical Ventilation To mantain adequate ventilation of dependent pulmonary parenchyma, two different STRATEGIES: A protective approach limits pulmonary STRESS (transpulmonary pressure), STRAIN (pulmonary overdistention) and ATELECT TRAUMA (opening and closing of alveoli), therefore also VILI (Ventilation induced Lung Injury) HIGH VOLUMES VENTILATION PEEP 5 cmH 2 0 TV 12 -15 ml/Kg PROTECTIVE VENTILATION PEEP 10 cmH 2 0 TV ≈ 8 ml/Kg
  5. 5. WEANING FROM MECHANICAL VENTILATION <ul><li>PEEP, “normal” TV </li></ul><ul><li>Forced diuresis , negative fluid balance </li></ul><ul><li>Rapid switch from controlled to assisted modes </li></ul><ul><li>Rapid extubation , irrespective of moderate-severe hypoxemia </li></ul><ul><li>Eventually, post-extubation C-PAP (helmet) and respiratory physiotherapy </li></ul>
  6. 6. RATIONALE FOR ACCELERATED WEANING FROM INVASIVE MECHANICAL VENTILATION <ul><li>CTEPH are “used” to severe hypoxemia </li></ul><ul><li>A gradual improvement of gas exchange is expected </li></ul>
  7. 7. CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION: SURGICAL TREATMENT ARTERIAL BLOOD GASES <ul><li>Gas exchanges returned to normal values in the majority of pts already at the 3-month control </li></ul>Pa O 2 50 60 70 80 90 100 Before PEA 3 months 1 year 2 years 3 years 5 years mm Hg Before PEA vs 3m, 1y, 2y, 3y and 5y p < 0.01 Pa CO 2 25 30 35 40 45 Before PEA 3 months 1 year 2 years 3 years 5 years mm Hg Before PEA vs 3m, 1y, 2y, 3y and 5y p < 0.02 O 2 -Sat 90 92 94 96 98 100 Before PEA 3 months 1 year 2 years 3 years 5 years % Before PEA vs 3m, 1y, 2y, 3y and 5y p < 0.02
  8. 8. RATIONALE FOR ACCELERATED WEANING FROM INVASIVE MECHANICAL VENTILATION <ul><li>CTEPH are “used” to severe hypoxemia </li></ul><ul><li>A gradual improvement of gas exchange is expected </li></ul>
  9. 9. RATIONALE FOR ACCELERATED WEANING FROM INVASIVE MECHANICAL VENTILATION <ul><li>CTEPH are “used” to severe hypoxemia </li></ul><ul><li>A gradual improvement of gas exchange is expected </li></ul><ul><li>Prolonged Invasive MV increases ICU stay and infections </li></ul>
  10. 10. WEANING FROM MV: The accelerated approach P = 0.02 P = 0.07 P = 0.03 P = 0.04
  11. 11. WEANING FROM MV : The accelerated approach PRE-EXTUB PRE-OP POST-EXTUB PRE-DISC POST-OP PRE-EXTUBATION PARAMETERS PaO 2 /FiO 2 246 ± 110 mmHg (113–491) PEEP 7.5 ± 2 cmH 2 O (4–10) FiO 2 0.5 ± 0.1 (0.3–0.7) POST-EXTUBATION C-PAP 2 / 3 patients PEEP 9 ± 1 cmH 2 O (8 – 10) Lenght 2.2 ± 1.4 days INITIAL MV PARAMETERS TV 666 ± 168 ml TV / Kg 8.5 ± 2.2 ml/Kg PEEP 9.7 ± 2.9 cmH 2 O (5–14) FiO 2 0.7 ± 0.2 (0.4–1)
  12. 12. HEMODYNAMIC MANAGEMENT AFTER PEA
  13. 13. Weaning from CPB <ul><li>Eventual SUPPORT to </li></ul>RV function Inotropes Dobutamine Ph 3 Inhibitors Epinephrine Systemic circulation Systemic Vasopressors Norepinephrine Pulmonary Vasodilators iNO Prostanoids Nitroprusside
  14. 14. HEMODYNAMIC MANAGEMENT <ul><li>Rapid weaning from Inotropes and iNO </li></ul><ul><li>Diuretics </li></ul><ul><li>Gradual weaning from vasopressors </li></ul><ul><li>No persistent PH </li></ul><ul><li>Good RV function </li></ul><ul><li>CO increase limit. </li></ul><ul><li>Intraop. Overload </li></ul><ul><li>Hypoxemia </li></ul><ul><li>Rapid MV weaning </li></ul><ul><li>Need for negative fluid balance </li></ul><ul><li>Effective surgery </li></ul><ul><li>Cardiac protection </li></ul>
  15. 15. HEMODYNAMIC MANAGEMENT RESULTS PRE-OP POST-OP POST-OP PRE-OP Mean ∆PVR -68 % Mean ∆CO +37 % Dobut. 5.9 ± 2.7 (2-12) 1.3 ± 0.8 (1 – 4) Norep. 0.2 ± 0.1 (0.01-0.5) 4.1 ± 3.7 (1 – 13) Dose mcg/Kg/min Lenght days
  16. 16. ANTICOAGULATION <ul><li>Prevention of local re-thrombosis: </li></ul><ul><li>Early start of SC heparin </li></ul><ul><li>Early resumption of Vit. K antagonism </li></ul><ul><li>PLT count daily monitoring (high risk HIT) </li></ul><ul><li>In our experience: </li></ul><ul><li>1° dose SC Heparin: 15 ± 9 hours (6 – 36) </li></ul><ul><li>1° dose VKA: 2.4 ± 1.3 days (1 – 6) </li></ul><ul><li>after ICU admission </li></ul>
  17. 17. POSTOPERATIVE COMPLICATIONS OF PEA <ul><li>Persistent PH and RH failure </li></ul><ul><li>Reperfusion pulmonary edema </li></ul><ul><li>Pulmonary hemorrhage </li></ul><ul><li>Neurologic disturbances </li></ul><ul><li>Infections </li></ul><ul><li>Heparin induced thrombocytopenia </li></ul><ul><li>Arrhythmyas </li></ul>
  18. 18. CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION: SURGICAL TREATMENT OPERATIVE MORTALITY
  19. 19. Low postoperative PVR Deaths 0.9 % High residual PVR 90 % 10 % CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION: SURGICAL TREATMENT Survivors 95.6 % Deaths 4.4 % 500 patients Deaths 30,1 %
  20. 20. Patients at risk for PPH? <ul><li>Distal disease </li></ul><ul><li>Inhomogeneous disease (unilateral!) </li></ul>
  21. 21. CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION: SURGICAL TREATMENT Secondary Small Vessel Disease Pervious branches Obstructed branches normal plexiform lesions muscular thickening
  22. 22. PREOPERATIVE EVALUATION <ul><li>PAC </li></ul>Prediction of responsiveness to surgery Outcome Pulm. An giography
  23. 23. Treatment of PPH <ul><li>Pulmonary vasodilators </li></ul>
  24. 24. PULMONARY VASODILATORS <ul><li>Which agent? </li></ul><ul><li>To decrease right ventricle afterload without systemic vasodilation and arterial oxygen desaturation, use a </li></ul><ul><li>SUPER-SELECTIVE AGENT: </li></ul><ul><li>Inhaled Nitric Oxide </li></ul><ul><li>Effective decrease of Pulmonary Vascular resistance </li></ul><ul><li>No effect on systemic circulation (pulmonary selective) </li></ul><ul><li>Vasodilates only ventilated lung areas (super-selective) </li></ul><ul><li>Decrease of V’/Q mismatch </li></ul><ul><li>Blunted reperfusion injury? </li></ul>
  25. 26. Ghofrani et al,JACC 2004; 44 (7): 1488-96
  26. 27. Treatment of PPH <ul><li>Pulmonary vasodilators </li></ul>
  27. 28. Treatment of PPH <ul><li>Pulmonary vasodilators </li></ul><ul><li>Inotropic support </li></ul><ul><li>Systemic vasopressors </li></ul><ul><li>Preload optimization </li></ul>
  28. 29. Treatment of PPH <ul><li>Pulmonary vasodilators </li></ul><ul><li>Inotropic support </li></ul><ul><li>Systemic vasopressors </li></ul><ul><li>Preload optimization </li></ul><ul><li>Control of O 2 consumption </li></ul><ul><li>Gas exchange optimization </li></ul><ul><li>Acidosis treatment </li></ul><ul><li>(ECMO) </li></ul>
  29. 30. <ul><li>PVR (114 ICU admission) </li></ul><ul><li>< 500 dynes*s*cm -5 > 500 dynes*s*cm -5 </li></ul><ul><li>Control Group Study group </li></ul><ul><li>77 % 23 % </li></ul>PVR (last) < 500 dynes*s*cm -5 > 500 dynes*s*cm -5 Functional group Persistent group 35 % 65 % High residual PVR after PEA: outcome in the Pavia experience
  30. 31. High residual PVR after PEA: Postoperative management Control Group (n = 88) Study group (n = 26) p ICU stay (days) 7.7 ± 9.1 18.2 ± 16.9 < 0.0005 Dobutamine (mcg/Kg/min) 5.9 ± 2.5 7.6 ± 2.9 < 0.01 Norepinephrine (days) 2.7 ± 2.6 4.8 ± 6.1 < 0.05 Fluid balance (ml) -1772 ± 2253 -875 ± 1231 < 0.05 Inhaled NO (n, %) 10 (16.1 %) 10 (41.7 %) < 0.05 Mech. Ventilation (days) 4.2 ± 6.0 11.5 ± 11.7 < 0.0001 PEEP (cmH 2 O) 7.7 ± 1.9 8.9 ± 2.1 < 0.01 FiO 2 (%) 58.6 ± 14.3 68.5 ± 14.9 < 0.005 CPAP (days) 1.8 ± 1.2 3.8 ± 4.7 < 0.02 Tracheotomy (n, %) 2 (3.2 %) 5 (20.8 %) < 0.02 Sedation (days) 3.0 ± 3.5 4.8 ± 5.2 < 0.05
  31. 32. High residual PVR after PEA: Postoperative complications Study group (n = 26) Control group (n = 88) p Hemorrhage (n, %) 2 (8.3 %) 7 (11.3 %) ns RPE (n, %) 10 (41.7 %) 10 (16.1 %) < 0.05 Arrhythmia (n, %) 9 (37.5 %) 16 (25.8 %) ns Pneumonia (n, %) 12 (50.0 %) 11 (17.7 %) < 0.01 Extubation failure (n, %) 10 (41.7 %) 7 (11.3 %) < 0.01 Pneumothorax (n, %) 2 (8.3 %) 7 (11.3 %) ns Neurologic disturbances (n, %) 5 (20.8 %) 7 (11.3 %) ns HIT (n, %) 1 (4.2 %) 3 (4.8 %) ns Mortality (n, %) 3 (11.5%) 5 (5.7%) ns
  32. 33. RAMI OCCLUSI REPERFUSION PULMONARY EDEMA CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION: SURGICAL TREATMENT Massive blood flow diversion from “remodeled” areas to those cleared by surgery RAMI PERVI
  33. 34. <ul><li>First described by Utley and Moser in 1982 </li></ul><ul><li>5-25 % incidence </li></ul><ul><li>Rarely life-treatening </li></ul>REPERFUSION P ULMONARY EDEMA <ul><li>Lenghten Invasive Mechanical Ventilation and ICU stay </li></ul>p<0.001 p<0.001
  34. 35. Reperfusion Pulmonary Edema <ul><li>Prevention : </li></ul><ul><li>CO increase limitation ? Protective MV ? </li></ul><ul><li>Negative Fluid Balance? </li></ul><ul><li>Treatment : </li></ul><ul><li>- iNO </li></ul><ul><li>- aggressive diuretic therapy </li></ul><ul><li>- PEEP , post-extubation C-PAP </li></ul><ul><li>- postural changes </li></ul><ul><li>- (ECMO) </li></ul>
  35. 36. PULMONARY HEMORRHAGE <ul><li>O.5 – 5 % incidence </li></ul><ul><li>3° cause of perioperative mortality </li></ul><ul><li>Soon after CPB weaning </li></ul><ul><li>Experience and skill of the surgeon </li></ul><ul><li>Advanced age </li></ul><ul><li>Residual PH </li></ul>Main Goals of Treatment Hemodynamic Stability Adequate Gas Exchange
  36. 37. Massive Pulmonary Hemorrhage After Pulmonary Thromboendarterectomy Gerard R. Manecke et al. Anesth Analg 2004;99:672-5
  37. 38. Treatment of pulmonary hemorrhage <ul><li>PEEP </li></ul><ul><li>Topical vasoconstrictors </li></ul><ul><li>Treatment of coagulopathy </li></ul><ul><li>Control of Pulmonary Artery Pressure </li></ul><ul><li>Bronchial blockade </li></ul><ul><li>Surgical repair </li></ul><ul><li>Lung resection or embolization </li></ul>
  38. 39. INFECTION <ul><li>In our series, the most frequent complication of postoperative period </li></ul><ul><li>Blood Stream, Urinary tract, Wound infections, but especially </li></ul><ul><li>(Ventilator Associated) Pneumonia </li></ul><ul><li>Risk factor: prolonged MV </li></ul>Management: Distal and protected pulmonary specimens Empiric antibiotic therapy Eventual down escalation
  39. 40. Pulmonary Samples Broncho Alveolar Lavage Plugged Telescopic Catheter Tracheal Aspirate
  40. 41. NEUROLOGIC DISTURBANCES <ul><li>Typical manifestations: </li></ul><ul><li>Prolonged Drowsiness </li></ul><ul><li>Temporary Delirium </li></ul><ul><li>Hallucinations </li></ul><ul><li>Agitation </li></ul><ul><li>Lower cardiac arrest times </li></ul><ul><li>Effective local cooling </li></ul><ul><li>Cerebral continuous monitoring </li></ul>Post-operative neurologic disorders rarely prevent extubation, maintenance of spontaneous breathing and normal patient recovery
  41. 42. H EPARIN I NDUCED T HROMBOCYTOPENIA <ul><li>Antibodies vs Heparin-PF4 complexes </li></ul><ul><li>Platelet activation </li></ul>Thrombocytopenia Venous and Arterial Thrombosis <ul><li>Typical features </li></ul><ul><li>Seroconversion and initial PLT count fall </li></ul><ul><li>( 5-10 days after Heparin exposure) </li></ul><ul><li>PLT < 50% or < 150 10 9 /L </li></ul><ul><li>( 7-14 days after Heparin exposure) </li></ul><ul><li>25% pts: Rapid Onset HIT </li></ul><ul><li>(Heparin exposure within the previous 100 days and residual circulating antibodies) </li></ul>
  42. 43. HIT in cardiac surgery patients <ul><li>Teatment of HIT </li></ul><ul><li>Alternative, Non-Heparin Anticoagulation: </li></ul><ul><li>Direct Thrombin Inhibitors </li></ul><ul><li>Factor Xa Inhibitors </li></ul><ul><li>Routine ultrasonography </li></ul><ul><li>VKA after PLT recovery </li></ul><ul><li>(PLT > 100-150 10 9 /L) </li></ul><ul><li>Vit K Antagonism reversal </li></ul><ul><li>(pts receiving VKA at HIT diagnosis) </li></ul><ul><li>PLT transfusion </li></ul><ul><li>(High bleeding risk or overt bleeding) </li></ul><ul><li>1-5 % incidence </li></ul><ul><li>DD with po PLT decrease: - secondary to CPB, hemodilution </li></ul><ul><li>- nadir day 2 after surgery </li></ul>

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