Peri-operatieve

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Peri-operatieve Respiratoire Complicaties
Dirk Himpe MD PhD ZNA Middelheim Antwerpen
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MORE IS MISSED BY NOT LOOKING THAN BY NOT
KNOWING Anonymous
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Chapters 28 29 Chapter 54 - pp 1389-95
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werkhypothese (algemene) anesthesie IS een
respiratoire complicatie
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anamnese KO versus epidemiologie evidence
wat kan er verkeerd gaan ? wat kan ik verkeerd
doen ?
anesthesieplan
wat is er verkeerd gegaan, wat kan er nog
verkeerd gaan en wat doe ik er aan?
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W. SMETANA - NEJM 1999
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Venous Admixture True Shunt
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Venous Admixture V/Q mismatch
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Spirometrie
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Resp Compl
0.06
0.94
_
niet abd niet thor
Resp Compl
0.9
0.3 0.4
hoog
Resp Compl
abdominale heelkunde
COPD
_
_
0.7 0.6
0.1
Resp Compl
0.16
laag
0.84
_
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new wheezing
new wheezing
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luchtweg weerstand
niet-rokers rokers
Eames et al. Anesthesiology, 841307-11, 1999
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of Baseline

Time after Anesthetic Initiated (Min)
Goff et al, Anesthesiology  2000 93404-408
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luchtweg weerstand na infusie oleinezuur
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1ste doel FRC behouden
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C dV/dP
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diafragma koepel
AA
atelectase gewoon t.g.v. inductie AA
G. Hedenstierna. Baillieres Clinical
Anaesthesiology, 101-30, 1996.
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2de doel collaps hyperexpansie voorkomen pro
tectieve beademings strategie
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Acute Lung Injury (ALI) - Niet-cardiaal
longoedeem Transfusion Related
(TRALI) Ventilator associated (VALI) Ventilator
induced (VILI) Ventilator associated pneumonie
(VAP) Volutrauma Atelectrauma (shear-stress
trauma) Biotrauma (vrijzetten mediatoren) Adult
Respiratory Distress Syndrome (ARDS) Barotrauma
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Barotrauma gtgt manifest extra-alveolar
air
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V entilator I nduced L ung I njury
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Parker JC et al. J Appl Physiol 1984, 571809-16
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Effect of 45 cmH2O PIP
Control 5 min 20
min
Dreyfuss D, Am J Respir Crit Care Med 1998 157
294323
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Volutrauma
Dreyfuss,D ARRD 1988, 137 1159 -gt P
independent
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PIP45 PEEP0
PIP14 PEEP0
PIP45 PEEP10
Webb Tierney ARRD 1974, 110 556
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C dV/dP
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Pinhu et al. Lancet 2003 361332-340
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Deflatie
Insuflatie
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Shearstress Injury Atelectrauma
Tearing at Bronchio-Alveolar Junction as lung
is recruited and allowed to collapse most
occurs in dependent lung zones
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Bron ARDS Network, NEJM 2000.
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Walder et al. EJA 22, 2005 786794
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Na 2 uur IPPV
Slutsky, A. S. Chest 1999 116 9-15S
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PEEP TV minimaliseren (6-8ml/kg) Plateau druk lt
35 cm H2O Beperken peak inspiratory
flow Inverse ratio I/R NUNN - p 416
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3de doel Airtrapping voorkomen
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COPD
normaal
TV
Hedley-Whyte J et al., J Clin Invest 4510, p
1543, 1966.
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Theres nothing thats good for everyone
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4de doel geen aspiratie
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Risk aspiration gastric contents
Extremes of ageEmergency statusTypes of
surgery (most common in cases of esophageal,
upper abdominal, or emergency laparotomy
surgery )Recent mealDelayed gastric emptying
and/or decreased lower
esophageal sphincter toneTraumaPregnancyPain
and stressDepressed level of conciousnessMorbid
obesityDifficult airwayPoor motor
controlEsophageal disease
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Maternal mortality from anesthesia and pulmonary
aspiration , 1952-1999 (Compiled from the Report
on Confidential Enquiries into Maternal Death in
the United Kingdom)
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pH lt 2.5 en/of volume gt 25 mL Postop
detoriatie al of niet na 2 uur
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EEFECTS OF DRUGS VS RISK OF ASPIRATION IN OBESE
PATIENTS

• Effect of drugs on the risk of pulmonary
  aspiration in obese patients, as reported by
  various studies (Amalraj S, personal
  communication).

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Recovery
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Mechanische
Luchtwegobstructie
Bronchospasme
Hypoxemie/hypercapnie
Resteffecten medicatie
Overhydratatie
Longoedeem
Quality Indicatoren
Pulmonaire Hypertensie
nood reintubatie
RH decompensatie
nabeademen
Cor Pulmonale
verlengd verblijf
Long-embolie
Pneumothorax (spannings-)
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ASA Closed Claims Study
Association of Death and Difficult Intubation
With Site of Airway Injury (n 244 claims)
Difficult Intubation( of site)
Routine Intubation( of site)
Death( of site)
Total( of 244)
Site
16(19)
67(81)
1(1)
83(34)
Larynx
27(66)
14(34)
9(22)
41(17)
Esophagus
17(44)
22(56)
3(8)
39(16)
Pharynx
21(62)
13(38)
5(15)
34(14)
Trachea
0(0)
24(100)
0(0)
24(10)
TMJ
3(25)
9(75)
0(0)
12(5)
Nose
9(82)
2(18)
3(27)
11(4)
Multiple Sites
P lt0.05 compared to laryngeal injury
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Severe Outcome, Standard of Care, and Frequency and Amount of Payment Severe Outcome, Standard of Care, and Frequency and Amount of Payment Severe Outcome, Standard of Care, and Frequency and Amount of Payment Severe Outcome, Standard of Care, and Frequency and Amount of Payment Severe Outcome, Standard of Care, and Frequency and Amount of Payment Severe Outcome, Standard of Care, and Frequency and Amount of Payment Severe Outcome, Standard of Care, and Frequency and Amount of Payment
  Severe Outcome Severe Outcome Standard of Care Standard of Care Payment Payment
Claims Brain Damage Death Appropriate Sub- standard Yes Median Amount
Airway Trauma (n 244) 0 21(9) 166(68) 43(18) 111(51) 25,000
Other General Anesthesia Claims (n 2,714) 397 (15) 1,099(40) 1,070(39) 1,253(46) 1,634(66) 125,000
P lt0.001 compared to general anesthesia claims. P lt0.001 compared to general anesthesia claims. P lt0.001 compared to general anesthesia claims. P lt0.001 compared to general anesthesia claims. P lt0.001 compared to general anesthesia claims. P lt0.001 compared to general anesthesia claims. P lt0.001 compared to general anesthesia claims.
Table 2
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