CONSIDERACIONES ANESTESICAS EN Esofagectomía

Presentación del tema: "CONSIDERACIONES ANESTESICAS EN Esofagectomía"— Transcripción de la presentación:

1 CONSIDERACIONES ANESTESICAS EN Esofagectomía
Enrique Anaya Residente Anestesia CES

2 Introducción Ca de esófago es la sexta causa de muertes relacionadas con el cáncer en todo el mundo. Los avances en técnica anestésica, la técnica quirúrgica y cuidados intensivos pop no han reducido notablemente la morbi-mortalidad. Hay pruebas de que la practica anestésica contribuye directamente a la mortalidad después de esofagectomía. Br J Anaesth 2001; 86:633–638

3 Valoración Pre-operatoria
Edad Avanzada Fumadores Historia de RGE Cardiopatía isquémica Tratamiento previos Otras comorbilidades % pacientes son ASA III y IV. Anaesthesia for oesophagectomy Curr Opin Anaesthesiol 20:15–

4 Morbilidad Peri-operatoria
Problemas Cardiacos Problemas Pulmonares Analgesia Epidural Manejo de Líquidos Peri-operatorios Anaesthesia for oesophagectomy Curr Opin Anaesthesiol 20:15–

5 Morbilidad Cardíaca Arritmias son la principal complicación médica.
Se presentan en el 20% a 60% de los casos. Fibrilación Auricular Complicaciones Pulmonares Fugas de Anastomosis Sepsis Taquicardias Supra ventriculares Estadía prolongada en UCI most are benign and may occur commonly during mediastinal manipulation in transhiatal esophagectomy,symptomatic arrhythmias may be associated with worse outcome. Anesthesiology Clin 26 (2008) 293–304

6 Morbilidad Cardiaca Calcio antagonistas y B bloqueadores disminuyeron la aparición de arritmias post operatorias. Digitalización profiláctica no mostro reducción en la incidencia de arritmias. Epidural Analgésica reduce incidencia de arritmias en Cx de resección pulmonar pero NO en esofagectomía. J Thorac Cardiovasc Surg 2005;129(5):997–1005.

7 Morbilidad Cardiaca Infarto Agudo del Miocardio.
Incidencia del 1% al 2%. Uso de B bloq peri operatorios disminuye la incidencia de IAM. Estatinas disminuyen la mortalidad después de Cx cardiaca mayor. a rct of metoprolol versus placebo in patients undergoing noncardiac surgery. (POISE) Am Heart J 2006;152(2):223–30.

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9 Morbilidad Pulmonar Principal causa de mortalidad hasta un 60%.
Aumento en la estadía en UCI y en Hospitalización. Predispone aparición de complicaciones post operatorias no fatales. Respiratory Complications After Esophagectomy Thorac Surg Clin 16 (2006) 35 – 48

10 Morbilidad Pulmonar SDRA – ALI Atelectasias Neumonía aspirativa
Neumonitis - Qulitorax TRALI VM Prolongada Sepsis Pulmonar FOM Respiratory Complications After Esophagectomy Thorac Surg Clin 16 (2006) 35 – 48

11 Morbilidad Pulmonar Factores Pre- operatorios
Radio y/o Quimioterapia previa. Edad. Función Pulmonar. Estado Inmuno - Nutricional. Factores Genéticos. Chemo-radiotherapy followed by surgery compared with surgery alone in squamous-cell cancer of the esophagus. N Engl J Med 1997patients receiving induction therapy had significantly increased perioperative mortality, deleterious effects of radiation on the lung. use of higher doses of induction radiation was associated with impaired pulmonary gas exchange,lower carbon dioxide diffusing capacity of the lungs after therapy, and development of ARDS . patients treated with preoperative chemoradiation had prolonged mechanical ventilation postoperatively. radiation therapy led to increased rates of pneumonia, higher in-hospital mortality than control groups. EDAD Proven preoperative factors associated with postoperative pulmonary morbidity is advanced age showed that pulmonary morbidity was associated with an age greater than 60 years. strong association between aspiration pneumonia and age,advanced age has been shown to be an independent predictor of mortality. are more likely to have underlying, subclinical swallowing disorders which may predispose them to postoperative complications such as aspiration and pneumonia. FP: demonstrated that abnormal baseline pulmonary function can negatively impact postoperative pulmonary status, pneumonia is more likely to occur in heavy smokers and in patients diagnosed as having chronic obstructive pulmonary disease before esophagectomy. prolonged mechanical ventilation postoperatively is associated with compromised preoperative pulmonary function–testing spirometry data, and they suggest that patients who have a FEV1 below 65% , CVF disminuida predicted are at highest risk for developing pulmonary complications after ER. EIN: Preoperative malnutrition has long been suspected as a risk factor for increased complications after ER. albumin level less than 3.5 mg/dL was an independent predictor of mortality, found that an albumin level less than 3.5 mg/dL was independently associated with increased pulmonary morbidity but not mortality after ER aggressive preoperative and perioperative enteral dietary as associated with reduced postoperative infectious complications among patients undergoing resection for gastrointestinal cancers, including ER. suggested that poor preoperative nutritional status might lead to an inadequate stress response at the cellular level. FG: have reasoned that because different markers of inflammation are altered among patients who have respiratory complications after ER. angiotensin II. In addition, stimulation of the angiotensin cascade can modulate endothelium function through pathways involved in cellular metabolism proliferation, or viability. The ACE D/D genotype has been associated with increased susceptibility to and increased mortality from ARDS. Respiratory Complications After Esophagectomy Thorac Surg Clin 16 (2006) 35 – 48

12 Morbilidad Pulmonar Factores Perioperatorios
Perdida de sangre intraoperatoria Tiempo Quirúrgico Localización del tumor Técnica quirúrgica patients requiring more than three units of transfused blood perioperatively had increased rates of pneumonia in the postoperative period. increased estimated blood loss was associated with increased mortality. the need for intraoperative blood transfusion was associated with in- creased rates of mortality. T: that long operative times are an independent predictor of pulmonary complications after ER. > 4-5H. L: Intrathoracic cancer of the esophagus, major pulmonary complications were seen in nearly 16% of patients and were responsible for 55% of deaths for resected esophageal tumors located above the carina. TEC: has also been assumed thatprocedures that avoid thoracic incisions, such as THE), would be associated with lower rates of pulmonary complications than transthoracic ER techniques Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med 2002 Perioperative morbidity was higher after TTE, but there was no significant difference in in-hospital mortality Pneumonia was encountered less frequently in the THE group, it has been assumed that less invasive procedures of any sort are associated with decreased rates of pulmonary complications Respiratory Complications After Esophagectomy Thorac Surg Clin 16 (2006) 35 – 48

13 Técnica Quirúrgica Mínimamente invasiva Laparotomía, Toracotomía
Toracoscopia, Laparoscopia Laparoscopia asistida Mediastinoscopia Laparotomía, Toracotomía Falta consenso y evidencia Complicaciones, Sobrevida VS Ju-Mei Ng. Perioperative Anesthetic Management for Esophagectomy. Anesthesiology Clin. 26 (2008)

14 Morbilidad Pulmonar Factores Post- operatorios
Disfunción Laringo-Faringea Dolor pop Filtraciones swallowing abnormalities, dysphagia, and poor airway protection he presence of laryngopharyngeal dysfunction in the postoperative period is most commonly attributed to RLN reported that nearly one third of patients who underwent THE experienced clinical dysphagia post-operatively, predisposing the patients to aspiration. F: Gastro-oesophageal anastomotic leak is a frequent complication of oesophageal surgery with a highmortality Anastomotic leaks are usually attributable to technical error or gastric conduit ischaemia The accurate diagnosis of a leak after oesophagectomy is difficult and many patients present with sepsis or (ARDS) Anastomotic leaks remain undiagnosed in up to 50%of patients. Itmay be appropriate to assume that any patient developing sepsis or ARDS immediately after an oesophagectomy has a leak until proved otherwise A retrospective analysis found the development of ARDS after oesophagectomy to be associated with intraoperative hypoxaemia and haemodynamic instability. The authors postulated that recurrent episodes of intraoperative hypotension and hypoxaemiamay have caused a series of tissue ischaemia and reperfusion injuries releasing proinflammatory mediators and activating leukocytes leading to lung injury Alternatively the intraoperative hypotension and hypoxaemia may have impaired distal gastric tube tissue oxygenation and the lung injury could have been secondary to gastric tube ischaemia or necrosis. Respiratory Complications After Esophagectomy Thorac Surg Clin 16 (2006) 35 – 48

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16 Estrategias Ventilatorias
Medidas Generales Ventilación mecánica protectora ( frec, Vol, PEEP fisiológico) Evitar el Volutrauma y el Atelectrauma. Mantener Presión Plateau < 35 cm H2O Perioperative Anesthetic Management for Esophagectomy Anesthesiology Clin 26 (2008) 293–304

17 Estrategias Ventilatorias
Ventilación de un solo pulmón. Vol. Corriente 5-6 ml/Kg. “PEEP optimo” Presión Pico < 30 cm H2O PCV con PEEP mejora la oxigenación y disminuye las presiones VA que VCV sin PEEP. Al utilizar PEEP, debe procurarse instaurar un nivel igual o ligeramente inferior al punto de inflexión inferior, con el objeto de comenzar el reclutamiento desde el mismo momento de inicio de la fase inspiratoria mecánica. Además, de esta forma se previene la lesión pulmonar aguda causada por el estrés mecánico que experimenta el alvéolo al ser insuflado desde una posición de subventilación hasta una máxima apertura, fenómeno este, implicado como una de las causas del trauma asociado a volumen (volutrauma)10. Estas afirmaciones, son la base del concepto de "PEEP óptima", Perioperative Anesthetic Management for Esophagectomy Anesthesiology Clin 26 (2008) 293–304

18 Intubación Selectiva Complicaciones hasta en un 30%.
Con el uso de fibrobroncoscopio < 1%. Toxicidad del oxigeno. Efecto de Re-ventilación. Aumento del SHUNT pulmonar. The 1996/1997 British national confidential enquiry into perioperative deaths found problems with double lumen tubes (DLTs), a feature of 30% of the deaths after oesophagectomy The proficiency of thoracic anesthesiologists in the positioning of double-lumen endobronchial tubes and bron- chial blockers and the routine use of fiberoptic bronchoscopy have helped reduce the incidence of hypoxemia during OLV to less than 1%. The high inspired oxygen concentration administered to the contralateral lung during OLV may promote the release of oxygen free radicals and reactive nitrogen species, which can lead to cellular damage and, ultimately, lung injury The reventilation of atelectatic lung after a period of OLV provoked severe oxidative stress, supporting the concept of reperfusion injury The degree of oxidative stress was related to the duration of OLV which is one of the features associated with ALI after elective esophagectomy Perioperative Anesthetic Management for Esophagectomy Anesthesiology Clin 26 (2008) 293–304

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20 Estudio clínico aleatorizado, prospectivo
54 pacientes aleatorizados en dos grupos, programados para cirugía de torax, con aislamiento pulmonar. 1 grupo (27) con TIVA (propofol, remifentanilo) 1 grupo (27) con Sevorane, remifentanilo Lavado broncoalveolar antes y después de VUP. Punto final primario: Medición de mediadores inflamatorios y celulares. Punto final secundario: Resultado clínico y eventos adversos. Resultados: Menos incremento en mediadores inflamatorios en el grupo de sevorane al igual que menos efectos adversos.

21 Estrategias Prevenir bronco-aspiración. Extubacion Premedicación.
Secuencia de intubación rápida. Asegurar Vía aérea. Aspiración de secreciones. Extubacion Temprana Vs Tardia? Aside from prophylactic pharmacologic management of GER, rapid-sequence induction, securing the airway with a cuffed endotracheal tube, and using gel lubrication on the tracheal cuff of the single- or double-lumen tube has been shown to reduce pulmonary aspiration in anesthetized patients Intraoperative tube substitution is common during esophagectomy and may subject the patient to additional risks of aspiration. It therefore is importantto perform proper and repeated suction of the nasogastric tube and oropharynx before and after extubation. Tracheal aspiration may occur after intubation. A prospective study of patients undergoing thoracotomy showedGORin 28%and tracheal acid aspiration,measured above the tracheal cuff, in 8%of patients. Inadequate tracheal cuff inflation or intraoperative cuff deflation and DLT repositioning are potentially disastrous. Tracheal acid aspiration also occurs after surgery. A prospective study, measuring tracheal pH for 48 h postoesophagectomy in awake, spontaneously breathing patients, showed that tracheal aspiration of gastric acid was very common, with multiple tracheal aspirations occurring in all patients studied Consideration should be given to measures to reduce tracheal aspiration: avoiding laryngeal injury at intubation, semirecumbent nursing and applying continuous low-grade suction to a double lumen nasogastric tube Ext: The potential complications associated with mechanical ventilation (including barotrauma and nosocomial pneumonia) and the side effects of sedation have led to studies looking at immediate or early extubation of patients after esophagectomy. Early extubation vs. late extubation after esophagus resection: a randomized, prospective study). Langenbecks Arch Chir Suppl Kongressbd 1998A randomized, controlled trial evaluating early and late extubation after esophagectomy found that the early extubation group after transthoracic esophagectomy had a higher hospital mortality than the prolonged ventilation group (9.8% versus 1.9%), although this difference did not reach statistical significance Although early extubation does not reduce morbidity independently, as part of a multipronged management plan it assists in decreasing the number of ventilator days and the duration of ICU stay and contributes to improved outcome, as demonstrated in several series Perioperative Anesthetic Management for Esophagectomy Anesthesiology Clin 26 (2008) 293–304

22 TIEMPO DE EXTUBACIÓN Extubación inmediata o temprana.
Ha mostrado ser seguro No asociado con morbilidad pulmonar Reduce la estancia en UCI Potencialmente puede reducir costos. Caldwell MT, et al. Timing of extubation after oesophagectomy. Br J Surg. 1993; 80 (12):

23 Epidural Analgésica. Ventajas. Control del dolor pop
Reducción complicaciones respiratorias Favorece extubación temprana Acorta la estadía en UCI Disminuye incidencia de filtraciones Mejor que opiodes IV y bloqueo para vertebral decreased pulmonary complications after ER with the use of epidural analgesia, from 30% to 13%. The superior dynamic pain relief after esophagectomy with TEA is important for effective cough, vigorous physiotherapy, and mobilization in the early postoperative period More recently, TEA for more than 48 hours reduced morbidity (pneumonia, reintubation), ICU stay, hospital stay, and in-hospital mortality when compared with either no epidural or TEA for less than 48 hours. The absence of epidural analgesia was an independent risk factor for pneumonia, and TEA was the key factor that facilitated immediate or early postoperative tracheal extubation. It also has been suggested that TEA is associated with a decreased incidence of anastomotic leakage. Ischemia of the gastric conduit and impairment of oxygen delivery have been postulated to be the main culprits in anastomotic leaks. TEA may improve microcirculation of the distal part of the gastric tube in an experimental model [67] and also facilitates intensive physiotherapy, thereby preventing hypoxemia. TEA improved microvascular perfusion of the gastric conduit in the anastomotic area after esophagectomy Perioperative Anesthetic Management for Esophagectomy Anesthesiology Clin 26 (2008) 293–304

24 BENEFICIOS < Filtración de la anastomosis
Isquemia del conducto gástrico Alteración en la entrega de O2 TEA mejora microcirculación gástrica distal TEA facilita fisioterapia, previene hipoxemia

25 Manejo de Líquidos Fluido terapia actual esta basada en algoritmos que tienen en cuenta supuesto déficit preoperatorio, mantenimiento, perdidas a 3 espacio. Perdidas sanguíneas se reponen con cristaloides relación 3:1 Esta practica tiende estados de sobre hidratación con sus respectivos efectos secundarios. Covert hypovolemia and inadequate tissue perfusion may lead to gut hypoperfusion with increased morbidity and duration of hospital stay whereas excessive perioperative fluid administration may delay recovery of gastrointestinal function, impair wound/anastomotic healing and coagulation, and impair cardiac and respiratory function Intraoperative Fluid Restriction Improves Outcome After Major Elective Gastrointestinal Surgery. Anesth Analg 2005;101:601–5

26 Sobre Hidratación Disfunción miocárdica.
Predispone a neumonía y falla cardiaca. Edema intestinal Alteraciones coagulación. Alteración de la cicatrización The patients with excessive intravascular volume had statistically significantly more frequent morbidity and longer length of ICU stay. Mortality in the patients who gained more than 10% body weight was 31.6% (versus 10.3% in the group that gained 10% body weight) The consequences of excessive intravascular volume are well recognized. It increases demands on cardiac function and may result in myocardial dysfunction and associated morbidity Increased extravascular lung water from excessive intravascular volume may predispose patients to pneumonia and respiratory failure Reported that a positive fluid balance exceeding 4000 mL was associated with an increased risk of postoperative pulmonary complications and in-hospital mortality It can lead to edema of the gut, which may inhibitgastrointestinal motility and prolong postoperative ileus and intolerance for enteric alimentation The potential for bacterial translocation and development of sepsis and multiorgan failure is also increased. An even more severe complication is the occurrence of abdominal compartment syndrome. Excessive crystalloids can also cause coagulation abnormalities. Increased cutaneous edema may decrease tissue oxygenation, which can lead to delayed wound healing.the third to the fifth postoperative day, when fluid is mobilized into the vascular space and the kidneys cannot diurese this extra fluid Intraoperative Fluid Restriction Improves Outcome After Major Elective Gastrointestinal Surgery. Anesth Analg 2005;101:601–5

27 Terapia Restrictiva Cristaloides 4-5 ml/Kg /Hr Perdidas Sanguíneas
Mantener balance de líquidos entre 1-2ml/Kg/Hr PVC < 5 mmHg Perdidas Sanguíneas Cristaloides o coloides hasta Hto > 25% Transfusión sanguínea Hto < 25% Volumen intra-operatorio promedio (949 ± 797 mL Vs 2386 ± 1307 mL) A retrospective study compared postoperative pulmonary complications in patients (n 112) undergoing transthoracic esophagectomy for carcinoma before and after introduction of restricted fluid administration regimen. The anesthetic technique included acombined general anesthesia with thoracic epidural analgesia. During the restricted period, crystalloid solution was 4–5 mL · kg1·h1, which was adminis- tered to maintain a fluid balance (i.e., [fluid infusion blood transfusion] [urinary volume blood loss])between 1 mL and 2 mL · kg1 ·h1 and a central venous pressure of 5 mm Hg. Intraoperative Fluid Restriction Improves Outcome After Major Elective Gastrointestinal Surgery. Anesth Analg 2005;101:601–5

28 Terapia Restrictiva Disminución morbilidad pulmonar.
Disminución de filtraciones. Acorta el periodo de recuperación. Disminución de la mortalidad?? The investigators found that restricted intraoperative fluid administration reduced postoperative pulmonary complications and shortened the recovery period in the hospital. The optimum perioperative fluid administration is a matter of continuing discussion. Instead of either a ‘‘restricted’’ or ‘‘liberalized’’ approach, the amount of fluid should be titrated individually to dynamic changes in appropriate monitoring. Intraoperative Fluid Restriction Improves Outcome After Major Elective Gastrointestinal Surgery. Anesth Analg 2005;101:601–5

29 MANEJOS LÍQUIDOS ESTRATEGIA DIRIGIDA POR METAS
RESTRICTIVO PRESIÓN DE PERFUSIÓN ENTREGA DE OXÍGENO <COMPLICACIONES PULM., < MORBILIDAD < ESTANCIA HOSPITALARIA LIBERAL EDEMA PULMONAR, ALI EDEMA INTERSTICIAL, ALTERA CICATRIZACIÓN > FILTRACIÓN Y PÉRDIDA SANGUÍNEA ESTRATEGIA DIRIGIDA POR METAS Ju-Mei Ng. Perioperative Anesthetic Management for Esophagectomy. Anesthesiology Clin. 26 (2008)

30 Conclusiones Mayoría de los pacientes que son sometidos a esofagectomía tienen riesgo a aspiración durante la inducción. Usar fibrobroncoscopio para intubación selectiva. Todo paciente que desarrolle SDRA o Sepsis de forma temprana se debe sospechar una filtración hasta que se demuestre lo contrario.

31 Conclusiones SDRA se asocia a hipoxemia e inestabilidad hemodinámica intra operatoria. Utilizar modos ventilatorios “protectores” EA debe ser usada en todo paciente a menos que exista contraindicación. Evitar la sobre hidratación. Hay mayor beneficio si hay una suma de intervenciones que utilizar cada una por separado.

32 GRACIAS!!