post operative management cteph

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

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

10. WEANING FROM MV: The accelerated approach P = 0.02 P = 0.07 P = 0.03 P = 0.04

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. HEMODYNAMIC MANAGEMENT AFTER PEA

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

18. CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION: SURGICAL TREATMENT OPERATIVE MORTALITY

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 %

21. CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION: SURGICAL TREATMENT Secondary Small Vessel Disease Pervious branches Obstructed branches normal plexiform lesions muscular thickening

26. Ghofrani et al,JACC 2004; 44 (7): 1488-96

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

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

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

37. Massive Pulmonary Hemorrhage After Pulmonary Thromboendarterectomy Gerard R. Manecke et al. Anesth Analg 2004;99:672-5

40. Pulmonary Samples Broncho Alveolar Lavage Plugged Telescopic Catheter Tracheal Aspirate