Crisis in Non-intubated Thoracic Surgery
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This document discusses crisis management during non-intubated video-assisted thoracic surgery (NI-VATS). It outlines several potential crisis situations including hypoxemia, respiratory acidosis, coughing, bleeding, and the need for conversion to general anesthesia or open thoracotomy. The author advocates for training in crisis resource management (CRM) principles including anticipation of issues, allocation of attention, and exercising leadership. Simulation is recommended to practice non-technical skills. Adhering to CRM processes and having experienced teams can help prevent crises during NI-VATS.
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Crisis in Non-intubated Thoracic Surgery
- 1. Crisis in Non Intubated VATS Dr. Jose Navarro-Martínez Anestesiology and Surgical Critical Care Hospital General Universitario de Alicante Spain jnavarro.martinez@gmail.com
- 10. What happens during a crisis? “Right now” resolution UnexpectedRare Complex
- 12. How do we train ourselves to prevent it? With knowledge With practice
- 14. Simulation How do we train ourselves to prevent it?
- 15. Non-technical skills How do we train ourselves to prevent it?
- 16. What is the correct way to manage a crisis?
- 17. Crisis Resource Management (CRM)
- 24. We started to work anestcritic@anestesialicante.com
- 25. Real life Continuous Analgesia Using a Multi-Holed Catheter in Serratus Plane for Thoracic Surgery. Font MC, Navarro-Martinez J, Nadal SB, Muñoz CG, Galiana-Ivars M, Montero PC Pain Physician. 2016 May;19(4):E684-6.
- 26. Experienced team: > 50 VATS +/- Difficult cases +/- bleeding compli Lateral intubation: >20 cases CRM in NI-VATS: Self resource
- 27. Hazardous attitudes / Production pressure (First case) Equipment: standard VATS CRM in NI-VATS: Self resource
- 28. CRM in NI-VATS: Anticipation and plans Endobronchial blocker Bronchofiberscope ready to use (3.7 mm) Propofol + fentanyl + rocuronium) Sugammadex Thoracic drainage (24 Fr) Neutral position of the head and occipital support Guedel canula Macintosh laryngoscope / 2 blade sizes Videolaringoscope Two sizes of double-lumen tubes 2 sizes of single lumen orotracheal tubes
- 34. CRM in NI-VATS: Cognitive aids
- 36. CRM in NI-VATS: Cognitive aids (App)
- 37. Call for help / Manage fixation errors: 2 anesthesiologists Allocate attention wisely /dynamically Simulation Exercise leadership and followership Surgical emergency Surgeon (severe bleeding) Medical emergency Anesthesiologist (oxygen desaturation) The 3erd nurse goes with the leader CRM in NI-VATS
- 38. CRM in NI-VATS: Clinical and critical situations
- 40. CRM in NI-VATS: Clinical and critical situations Hypoxemia Healthy patients Worse Objective: SatO2 >95% Venturi vs High flow Respiratory acidosis Common. Tolerated. Hypoventilation Dispnea At the beginning Always explain to the patient Cough Very usual Lidocaine 1-2mg/Kg/h /iv Aerosolized 2-4% lidocaine Intrathoracic vagal block Anxiety When they feel dispnea Careful selection of patients Massive bleeding Two peripheral venous catheters in the contra side of the surgery
- 41. CRM in NI-VATS: Clinical and critical situations Conversion to General Anesthesia Respiratory acidosis + pH <7.1 +taquipnea >30 rpm Hypoxemia (pO2 <60 mmHg) despite HFV nor NIV Continuous cough despite blockade Anxiety attack with no improvement with sedation Patient voluntary desire of conversion
- 42. CRM in NI-VATS: Clinical and critical situations Conversion to open thoracotomy and GA Moderate to major bleeding Uncontrollable with single incision/awake procedure Requires more important maneauvers (pulmonary artery clamp, primary suture, reconstruction)
- 45. CRM in NI-VATS: Clinical and critical situations Conversión to VATS multiportal Adhesions lung to chest wall > 50% surface Large tumors (central and anterior)hilar structures Non-adequate lung collapse Mild bleeding Conversion to open thoracotomy Impossibility of nodule palpation through the single-incision
- 46. Conclusions NI-VATS is a potential source of crisis situations Train and Follow the CRM principles Simulation essential learning non-technical skills Training the lateral intubation is necessary Everybody “feels” as part of the team
Editor's Notes
- My presentation I am anesthesiologist of Thoracic anesthesia and Surgical Critical Care. Hospital 900 beds from Alicante Spain…..We have lot of things in common…..Sunny and hot Pensar en algo gracioso “Caer bien para empezar” Thank you very much for the invitation, for me is a great honor to be here. My topic is Crisis َباحُ الخَير Buenas tardes masa‘ul jair
- Abdelaziz bin Saud
- Ljungqvist O,
- All of the people who are here have managed
- Lots of: people, things to do, monitors Cognitive block The one who comes has an open mind
- Medical shool. That´s enough??
- There is an increased interested in the way we manage the Crisis situacions. Like the policeman they have to train them selfves to manage a kidnaping
- NTK are very important in our job We work with a lot of people, .nurses surgeons. The rhird leg with kwonlege and skils Specially in our work. It´s not so important for a Dermatohlogist
- Habilidades no técnicas
- The basis were made by Prof Gaba in stanford 20 years ago. We will describe them one by one
- The first thing to do was to implement the CRM principles in a specific surgery as is the NIVATS
- This is very obious but sometimes is not been done There is a special issue Bare in mind that we only included patients candidates to NIVATS The first thing to know is that this is not more difficult than do it in the supine position. Second, the lateral position of the patient is very useful for the entire team. The patient can put himself in the most comfortable position (preventing iatrogenic stretching injuries of the brachial plexus). The surgeon can obtain the best surgical approach without harming. The anesthesiologist can intubate without increasing the risk. The nurse doesn’t have to move the entire heavy weighted patient once he is asleep. Theoretically, everybody is happy. How is the correct way to do it? As we can see in Figure 2, the head must be in a neutral position, using a couple of surgical pillows and an occipital support to prevent that the head goes backwards during the laryngoscopy. Ventilation is more easily performed than in supine position, actually this position is the safe position to prevent lung aspiration and the hypopharyngeal structures won’t easily cause an airway obstruction. Correct manual ventilation is normally achieved without the need of Guedel airway, regardless of the side to intubate. Laryngoscopy and intubation in right sided position are usually more hazardous compared to the left sided. This is because it is more difficult to direct the double lumen tube properly, even if normally we can do it without help of intubating introducers or similar. Once the double lumen tube is inside the trachea, it is generally well positioned the first time. We have to pay particular attention to patients with predictive criteria of difficult airway; those patients are not excluded from the NI-VATS (13), in which we directly use the Airtraq® videolaringoscope and the bronchofiberscope.
- To solve this problem not all the surgeons or anesthesiologists can perform a NI-VATS, only the ones that knows their own limitations and try to improve them. The NI-VATS is scheduled the first case of the day.
- To solve this problem not all the surgeons or anesthesiologists can perform a NI-VATS, only the ones that knows their own limitations and try to improve them. The NI-VATS is scheduled the first case of the day.
- To solve this problem not all the surgeons or anesthesiologists can perform a NI-VATS, only the ones that knows their own limitations and try to improve them. The NI-VATS is scheduled the first case of the day.
- Temas actualizados conjuntamente con especialistas en rayos (aportan los criterios de Aspect) y cardio
- Pre-crisis: Prevención y aumentar el conocimiento Crisis: Razones obvias, mejorar el resultado Post-crisis: como elemento objetivo para evaluar un acontecimiento adverso.
- You have to get the big picture to solve the small problem Beetwen the surgeons and the anestheisioloisgt we have differente criteria ( just to say it in a nice way)
- Once the lung is collpased Open neumotorax
- Once the lung is collpased Open neumotorax
- Cough One of the very usual problems during the NI-VATS is the cough of the patient. Cough receptors are located mainly on the posterior wall of trachea, pharynx, and mucosa of bronchus. Impulses caused by stimuli travel via the vagus nerve to the medulla of the brain, and trigger a cough. The predominance of vagal tone after sympathetic block by TEA might potentially increase bronchial tone and reactivity. There are several ways to block this coughing reflex, but none of them really suppress it 100% without risks: The first option is to administrate 1-2 mg/Kg of lidocaine and then a continuous perfusion , but the risk of reaching the local anesthetic toxicity is very near. The second way is to use inhalation of aerosolized 2-4% lidocaine in a high oxygen flow for about 30 min before the surgery. The third option is to do an intrathoracic vagal block with 2 mL of 0.25% bupivacaine adjacent to the vagus nerve (17) under direct thoracoscopic vision at the level of the azygous vein in the right side, and just below the aortopulmonary window in the left side, in order to avoid laryngeal recurrent nerve palsy. It has the risk of affecting heart rate, breathing rate, and blood pressure. This option has one variant, which consists on aerosolizing Bupivacaine 0.25% over the visceral pleura and the posterior mediastinal pleural through the vagus nerve course. The last one is to block the ipsilateral stellate ganglion with 10 mL of 0.25% bupivacaine. This aspect is on continuous evolution, what we usually do is a mixture of all the options. We start aerosolizing lidocaine 30 min before the surgery to anesthetize the tracheobronchial tree, and then we instill directly the intrathoracic vagus nerve or aerosolize the visceral and posterior mediastinal pleura with Bupivacaine. If with those maneuvers we do not obtain good results, we then add intravenous lidocaine to upgrade the effect.
- Cough One of the very usual problems during the NI-VATS is the cough of the patient. Cough receptors are located mainly on the posterior wall of trachea, pharynx, and mucosa of bronchus. Impulses caused by stimuli travel via the vagus nerve to the medulla of the brain, and trigger a cough. The predominance of vagal tone after sympathetic block by TEA might potentially increase bronchial tone and reactivity. There are several ways to block this coughing reflex, but none of them really suppress it 100% without risks: The first option is to administrate 1-2 mg/Kg of lidocaine and then a continuous perfusion , but the risk of reaching the local anesthetic toxicity is very near. The second way is to use inhalation of aerosolized 2-4% lidocaine in a high oxygen flow for about 30 min before the surgery. The third option is to do an intrathoracic vagal block with 2 mL of 0.25% bupivacaine adjacent to the vagus nerve (17) under direct thoracoscopic vision at the level of the azygous vein in the right side, and just below the aortopulmonary window in the left side, in order to avoid laryngeal recurrent nerve palsy. It has the risk of affecting heart rate, breathing rate, and blood pressure. This option has one variant, which consists on aerosolizing Bupivacaine 0.25% over the visceral pleura and the posterior mediastinal pleural through the vagus nerve course. The last one is to block the ipsilateral stellate ganglion with 10 mL of 0.25% bupivacaine. This aspect is on continuous evolution, what we usually do is a mixture of all the options. We start aerosolizing lidocaine 30 min before the surgery to anesthetize the tracheobronchial tree, and then we instill directly the intrathoracic vagus nerve or aerosolize the visceral and posterior mediastinal pleura with Bupivacaine. If with those maneuvers we do not obtain good results, we then add intravenous lidocaine to upgrade the effect.
- شshukran yazilan ُكراً جَزيّلاً
- شshukran yazilan ُكراً جَزيّلاً