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LOGO Anestesiologia UIS Hipoxemia perioperatoria Dr. Raúl Vásquez.

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Presentación del tema: "LOGO Anestesiologia UIS Hipoxemia perioperatoria Dr. Raúl Vásquez."— Transcripción de la presentación:

1 LOGO Anestesiologia UIS Hipoxemia perioperatoria Dr. Raúl Vásquez

2 LOGO Historia La anestesia general se asocia con hipoxemia

3 LOGO Fisiologia Oxigenación Entrega O2 (DO2) Consumo O2 (VO2) Metabolismo celular aerobico Oxygenation and mechanisms of hypoxemia

4 LOGO Disminucion de la entrega de oxigeno de la atmosfera a la sangre arterial (oxigenación insuficiente) Definicion Hipoxemia Disminucion de la entrega de oxigeno de la sangre arterial a los tejidos Hipoxia Monitoring Respiratory Function

5 LOGO Incidencia The incidence of hypoxemia during surgery: evidence from two Institutions Duration of Hypoxemic Episodes at Hospitals A & B. The incidence and maximum duration of intraoperative hypoxemic episodes. Episodes are grouped by maximum duration per patient for both hypoxemic (SpO2\90) and severely hypoxemic episodes (SpO2 B 85). The percentage of patients experiencing two consecutive minutes or longer of hypoxemia and severe hypoxemia was 6.8% and 3.5%, respectively Can J Anesth/J Can Anesth (2010) 57:888–897 Hipoxemia perioperatoria

6 LOGO Incidencia Can J Anesth/J Can Anesth (2010) 57:888–897 Hipoxemia perioperatoria 1 : 15 Hipoxemia por dos minutos 1 : 64 Hipoxemia 5 minutos ˃ 3 millones pacientes hipoxemia 5 min

7 LOGO Efectos Deletereos Altera cicatrización, integridad anatomosis y resistencia a infección Arch Surg 1997; 132: Arch Surg 1997; 132: N Engl J Med 2000; 342: Translocacion bacteriana GI – Sepsis Arch Surg 1996; 131: Disfunción cognitiva – delirio Am J Med 1981; 79: Br J Anaesth 1994; 72: GC, precipita arritmias, hipertensión arterial, Taquicardia, isquemia Anesthesiology 1999; 91: Br Heart J 1993; 69: 3-5 Hipoxemia perioperatoria

8 LOGO Medidas Oxigenacion Examen físico –Cianosis franca 5 g/dl deoxihemoglobina SaO 2 67% GASA gold standard PaO 2 SaO 2 Quinto signo vital –Proyecto global pulso oximetria OMS pulso oximetros Hipoxemia perioperatoria Pulse oximetry

9 LOGO Oximetría de Pulso Hipoxemia perioperatoria Monitoring Respiratory Function

10 LOGO Pulso Oximetria Depicted here is the oxyhemoglobin dissociation curve for normal adult hemoglobin (Hemoglobin A, solid line). Note that hemoglobin is 50 percent saturated with oxygen at a partial pressure of 27 mm Hg (ie, the P50 is 27 mm Hg) and is 100 percent saturated at a pO2 of approximately 100 mm Hg. Depicted here are curves that are "left-shifted" (blue line, representing increased oxygen affinity) and "right-shifted" (red line, decreased oxygen affinity). The effect of right- or left-shifting of the curve is most pronounced at low oxygen partial pressures. In the examples shown, the right-shifted curve means that hemoglobin can deliver approximately 70 percent of its attached oxygen at a pO2 of 27 mm Hg. In contrast, the left-shifted hemoglobin can deliver only about 35 percent of its attached oxygen at this pO2. A high proportion of fetal hemoglobin, which has high oxygen affinity, shifts this curve to the left in newborns. Hipoxemia perioperatoria Pulse oximetry

11 LOGO Oximetria de Pulso Aumenta deteccion hipoxemia 20 veces Dx temprano –Intubación endobronquial –Hipoventilacion Pacientes monitorizado –50% menos eventos isquemia miocárdica Hipoxemia perioperatoria Global Pulse Oximetry Project

12 LOGO Oximetría de Pulso La monitorización perioperatoria con oximetría de pulso no resulta en mejores resultados, efectividad o eficacia. No reduce transferencia a UCI ni mortalidad y es incierto si existe beneficio real en Cx Cardiotoracica Hipoxemia perioperatoria Oximetría de pulso para la monitorización perioperatoria 2008

13 LOGO Oximetría de Pulso Mala Colocacion Artefacto Movimiento Mala Colocacion Artefacto Movimiento Luz Ambiental Luz Ambiental Radiación Electromagnetica Radiación Electromagnetica Fuentes comunes de artefacto Pulse oximetry

14 LOGO Hg Anormales Hipoperfusion Hipotermia Congestion Venosa Pigmentacion Piel Colorantes Vitales EsmalteAnemia Oximetría de Pulso Errores relacionados Con el Paciente Pulse oximetry

15 LOGO Medidas Oxigenacion Tension arterial de O2 PaO2 Gradiente Alveolo-arterial O2 Radio PaO2/FiO2 Radio Oxigeno Alveolo-arterial Indice de Oxigenacion Fraccion Shunt Hipoxemia perioperatoria Oxygenation and mechanisms of hypoxemia

16 LOGO Gradiente A-a Diferencia cantidad oxigeno en el alveolo PAO 2 y cantidad de O 2 disuelto en el plasma PaO 2 Varia con la edad –Gradiente A-a= (edad/4) + 4 –10 mmHg jovenes, 30mmHg 70 años Hipoxemia perioperatoria Oxygenation and mechanisms of hypoxemia

17 LOGO Gradiente A-a

18 LOGO Gradiente A-a Hipoxemia perioperatoria Hipoxemia Causa PIO2 Hipoventilacion Mismach V/Q Shunt D-I Ttno Difusion P(A-a)O2 Normal Rta O2 100% No Mejora PaCO2 Normal Normal Anesthesiology Clinics of North America - Volume 19, Issue 4 (December 2001)

19 LOGO Gradiente A-a FiO 2 = PAO 2 y PaO 2 –La PAO 2 desproporcionadamente ˂ 40 años FiO2 100% 8 a 82 mmHg ˃ 40 años FiO2 100% 3 a 120 mmHg Hipoxemia perioperatoria Oxygenation and mechanisms of hypoxemia

20 LOGO Fraccion Shunt D-I Gold standar de oxigenacion eficiente en los pulmones Shunt 50%= Falla respiratoria severa Shunt 5%= Normal Monitoring Respiratory Function

21 LOGO Medidas Oxigenacion 33 pctes con SDRA Relacionaron shunt con radio O2 A/a, PaO2/FiO2, gradiente A-a, IR, radio O2 a/A PaO2/FiO2 variable mas facil que predice con exactitud el grado de shunt en falla respiratoria Hipoxemia perioperatoria Oxygen derived variables in acute respiratory failure Crit Care Med Aug;11(8):646-9

22 LOGO Radio PaO2/FiO2 Normal= 300 a 500 mmHg ˂ 300 mmHg= Intercambio gaseoso anormal ˂ 200 mmHg= Hipoxemia severa se correlaciona con Shunt ˃ 20% Hipoxemia perioperatoria Oxygenation and mechanisms of hypoxemia

23 LOGO Causas Oxígeno inspirado Hipoventilación Alteración V/Q Difusión limitada. Hipoxemica Anemica Circulatoria Afinidad Histotoxica Hipoxemia Hipoxia Monitoring Respiratory Function Oxygenation and mechanisms of hypoxemia Shunt Derecha-Izquierda

24 LOGO Bajo PIO2 PERIOPERATIVE HYPOXIA The Clinical Spectrum and Current Oxygen Monitoring Methodology Barometric pressure (PB) and inspired oxygen (O2 ) tension or partial pressure in millimeters of mercury (mm Hg) related to altitude in thousands of feet and in meters. The PB at Denver, the Mile High City, is 640 mm Hg, and the PIO2 there is 134 mm Hg in dry air. Point 1 is at 5500 meters in the Peruvian Andes, the highest point of continuous human habitation, where the PB is 380 mm Hg, and the PIO2 in dry air is 80 mm Hg. The air is not dry at the alveolus. By the time the inhaled air reaches the alveolus, it is saturated with H2 O vapor (47 mm Hg at 37°C irrespective of the elevation or PB). At 5500 meters, H2 O vapor decreases the PIO2 from 80 to 70 mm Hg). Supplemental oxygen is usually required at point 2, although Mount Everest has been climbed without O2. Point 3 represents the highest ascent with O2 but without superatmospheric pressure. Anesthesiology Clinics of North America - Volume 19, Issue 4 (December 2001) Hipoxemia perioperatoria

25 LOGO Ecuación 1 PIO 2 = PAO 2 Anesthesiology Clinics of North America - Volume 19, Issue 4 (December 2001)

26 LOGO Morgan, Edward: Anestesiologia clinica – Seccion I capitulo 3 y Flujometros Guarda Hipóxica –Mecánica, neumática o electrónica –Garantiza FiO2 25% Flujo Metabolico O 2 : Peso ¾ x 10

27 LOGO Hipoventilación Ventilación minuto inadecuada (CO 2 ) –FR x VC Normal Anesthesiology Clinics of North America - Volume 19, Issue 4 (December 2001) Hipoxemia perioperatoria Hipoventilado

28 LOGO PAO2=0.21x(760-47)-PaCO2/ =0.21x(760-47)-40/0.8Ventilacion Normal PaCO =0.21x(760-47)-80/0.8 Hipoventilacion PaCO2 80 FiO2 21% 114=0.3x(760-47)-80/0.8 Hipoventilacion PaCO2 80 FiO2 30% Corrige al FiO 2 Gradiente A-a normal Hipoventilación Oxygenation and mechanisms of hypoxemia Anesthesiology Clinics of North America - Volume 19, Issue 4 (December 2001)

29 LOGO El balance V/Q es complejo –Volumen ventilatorio –Presion alveolar –Compliance pulmon y caja toracica –Resistencia de la via aerea –Gravedad –Posicion del paciente –Flujo sanguineo pulmonar –Modo ventilatorio Imbalance V/Q Anesthesiology Clinics of North America - Volume 19, Issue 4 (December 2001) V sin Q Espacio Muerto Q sin V Shunt

30 LOGO Imbalance V/Q Enfermedad pulmonar obstructiva Enfermedad vascular pulmonar Enfermedad intersticial Anesthesiology Clinics of North America - Volume 19, Issue 4 (December 2001)

31 LOGO Falla Respiratoria Hipoxemica Aguda Hipoventilacion Alveolar Perioperatoria Aguda Hipoperfusion Shock Tipo IV Tipo I Tipo II Tipo III Atelectasias, dolor incisional analgesia inadecuada, alteracion tos, uso de tabaco 6 semanas precx sobrehidratación Critical Care. Just the Facts 2007

32 LOGO Atelectasias In normal lungs (A), the alveolar inflation and vascular prfusion are associated with low stress and are not injurious. Two separate barriers form the alveolar– capillary barrier, the microvascular endothelium, and the alveolar epithelium. e Pulmonary Atelectasis A Pathogenic Perioperative Entity Anesthesiology, V 102, No 4, Apr 2005 In contrast, with atelectasis (B), alveolar inflation and deflation may be heterogeneous, and the resulting airway stress causes epithelial injury. Because the blood vessels are compressed, perfusion may be traumatic because of flowinduced disruption of the microvascular endothelium. Both epithelial and endothelial injury may initiate or ropagate lung injury. This figure depicts the advanced stage of lung injury caused by atelectasis. The initial injury is simple collapse of alveoli. However, with time, this leads to an inflammatory reaction. As the derecruited lungs cause epithelial injury and loss of epithelial integrity, both type I and type II alveolar cells are damaged. Injury to type II cells disrupts normal epithelial fluid transport, impairing the removal of edema fluid from the alveolar space. In ddition to collapse, derecruited lungs also become fluid filled. Neutrophils adhere to the injured capillary endothelium and migrate through the interstitium into the alveolar airspace.In the airspace, alveolar macrophages secrete cytokines, interleukin (IL)-1, -6, -8, and -10, and tumor necrosis factor (TNF)-, which act locally to stimulate chemotaxis and activate neutrophils. IL-1 can also stimulate the production of extracellular matrix by fibroblasts. Neutrophils can release oxidants, proteases, leukotrienes, and other proinflammatory molecules, such as platelet-activating factor (PAF). MIF macrophage inhibitory factor.

33 LOGO Shunt (Qs/Qt) Derecha a izquierda –Anatomico Intracardiaco, MAV, Venas bronquiales –Transpulmonar Area Q no V –Atelectasias –Neumonia –Edema pulmonar –Aspiracion Anesthesiology Clinics of North America - Volume 19, Issue 4 (December 2001)

34 LOGO Atelectasias Anesthesiology, V 102, No 4, Apr 2005 Reabsorcion Gas Compresion Pulmonar Alteracion Surfactante Tres sets de mecanismos causan o contribuyen a la formacion de atelectasias Etiologia y Patogenesis

35 LOGO Compresion Pulmonar Hagberg: Benumof's Airway Management, 2nd ed

36 LOGO Reabsorcion Gas Anesthesiology, V 102, No 4, Apr 2005 Oclusion completa de la via aerea FiO 2 V a /Q Bajo

37 LOGO Atelectasias Anesthesiology, V 102, No 4, Apr 2005

38 LOGO AtelectasiasHipoxemia Alt Compliance Pulmonar RVP Lesionpulmonar VC bajo, hiperoxia (microatelectasias) Reversada por hiperinflacion Reduccion volumen pulmonar, macroatelectasias. Empeora oxigenacion sistemica Vasoconstriccion hipoxica pulmonar Tension Oxigeno alveolar y venoso mixto Atelectasias + VC Prevenida con PEEP Anesthesiology, V 102, No 4, Apr 2005 Complicaciones

39 LOGO Atelectasias Anesthesiology, V 102, No 4, Apr 2005 Pulmon sano Hiperinsuflación 3 sucesivas -20 cm H2O x 10 seg -30 cm H2O x 15 seg -40 cm H2O x 15 seg Nunn et al -40 cm H2O x 40 seg Tusman Reclutamiento alveolar Depende del Pulmon ! Prevencion - Reversion

40 LOGO Schematic representation of the Alveolar Recruitment Strategy: PEEP is incremented in 3 steps of 5 cmH 2 O each. The vertical rectangles represent tidal breathing with a tidal volume of 7-9 mg/kg BW at a respiratory rate of 8 bpm. At a PEEP of 15 cmH 2 O tidal volumes are increased until a maximum tidal volume of 18 ml/kg or a peak airway pressure of 40 cmH 2 O is reached. These settings are applied for 10 breaths. Thereafter, tidal volumes are reduced to the previous values. Finally, PEEP is set to a level of 5 cmH 2 O in two steps. Reclutamiento Alveolar Tusman G et al. Alveolar Recruitment Strategy normalizes arterial oxygenation Pulmón Sano

41 LOGO Atelectasias Anesthesiology, V 102, No 4, Apr 2005 Pulmon sano Hiperinflación pasiva 3 sucesivas -20 cm H2O x 10 seg -30 cm H2O x 15 seg -40 cm H2O x 15 seg Nunn et al -40 cm H2O x 40 seg Tusman Reclutamiento alveolar Pulmon Lesionado -Evitar VC, presiones pico elevadas, atelectrauma -Usar PEEP Depende del Pulmon ! Prevencion - Reversion

42 LOGO Sobredistension Baro - Volotrauma - LAD VENTANA SEGURA Atelectasias Estres por deslizamiento, alteracion por surfactante Ventilacion Mecanica Barboza, Miguel Fisiologia de la ventilacion Unipulmonar

43 LOGO

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45 Gracias! Por la Paciencia

46 LOGO Incidencia Management of the Difficult Airway A Closed Claims Analysis * Percent of row resulting in death or brain damage (death/BD). Bonferroni P 0.04, 1993–1999 vs. 1985–1992. Anesthesiology, V 103, No 1, Jul 2005


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