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A Case of Oxygen Desaturation at POR

A Case of Oxygen Desaturation at POR. R1 Minghui Hung Department of Anesthsiology, NTUH. Case Summary. 61-year-old male DM and HTN under regular medication control Smoking: 2 PPD for more than 40 years Alcohol: socially. Case Summary.

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A Case of Oxygen Desaturation at POR

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  1. A Case of Oxygen Desaturation at POR R1 Minghui Hung Department of Anesthsiology, NTUH

  2. Case Summary • 61-year-old male • DM and HTN under regular medication control • Smoking: 2 PPD for more than 40 years • Alcohol: socially

  3. Case Summary • Lower third esophageal cancer status post CCRT and transhiatal esophagectomy with gastric tube reconstruction and jejunostomy in April, 2000 • Complicated with mild leakage at cervical anastomosis site.

  4. Case Summary • Mild dysphagia when eating solid food • Recurrent pus discharge from left neck wound with local erythematous swelling • Ventral hernia and direct type inguinal hernia

  5. Induction Course • Pre-induction SpO2: 97% • Induction with fentanyl (100μg), thiopental (250mg), succinylcholine (100mg), atracurium (30mg), • adjuncts with Rubinol (0.3mg), 2% Xylocaine (100mg)

  6. Induction Course • Endotracheal intubation was performed with laryngoscope. • Direct visualization of oropharyngeal secretions around the glottis.

  7. Peri-operative Course • Peri-operative course was uneventful except one episode of desaturation decreased to 95%. • Aminophylline 1 amp intravenous drip and Solu-medrol 2 vials was given. • Extubation after operation and sent to POR with Atrovent (1amp) and Bricanyl (1amp) inhalation.

  8. At POR • Intra-operative IVF: 1500ml; urine output: 900ml • Oxygen saturation decreased to 89-90% when arriving POR • Tachypnea and dyspnea with restless • Bilateral inspiratory rales and crackles was noted • No wheezing

  9. At POR • Oxygen saturation decreased to 75%, Ambu bag was used and SpO2 return to around 90% • ABG showed no obvious acid-base disorder, nor electrolyte imbalance, but hypoxemia was noted

  10. Arterial Blood Gas Analysis • pH: 7.350 • PCO2: 39.8 mmHg • PO2: 53.3 mmHg • Na: 141 mM, K: 3.8 mM, Cl: 113 mM, Ca: 1.02 mM • Glucose: 192 mg/dL • Hb: 15.2 g/dL • HCO3: 22.1 mM • BE: -3.7 mM • O2Sat: 85.6% • Anion Gap: 10 • Osmolarity: 282 mOsm

  11. At POR • Demerol 25mg for analgesia • Lasix 1 amp was used for diuresis • Portable CxR • Complete EKG

  12. Chest X-ray CxR at POR Previous CxR

  13. Complete EKG CK: 85 U/L CK/MB:8.9 U/L Troponin I: 0 ng/ml

  14. At POR • Blood pressure dropped to 75/48 mmHg, Dopamine set 10 ml/hr was used and emergent intubation was performed at POR • Sent to ICU with stable vital signs

  15. Intensive Care Unit • Transthoracic cardiography • good LV contractility • no RA or RV dilatation • hypovolemia

  16. Intensive Care Unit • At ICU, empirical antibiotics • Cefmetazone 2vials q8h • Gentamicin 1vial q12h • Inotropic agents • Dopamine • Levophed • Fresh frozen plasm transfusion • Inhalation brochodilators • Mechanical ventilator support (PEEP)

  17. Intensive Care Unit • Cardiac enzyme

  18. Intensive Care Unit • Hemogram

  19. Intensive Care Unit • Coagulation study

  20. Intensive Care Unit • Blood chemistry study

  21. Intensive Care Unit • Inotropic agents was titrated and DC at day 2 • Ventilator weaning and extubation at day 3 • No more dyspnea • Bilateral rales and crackles improved except RLL • Back to general ward on day 5

  22. What happened?→Pulmonary Edema • Hemodynamic edema LV failure, mitral stenosis Left-to-right cardiac shunt, fluid overload, severe anemia • Permeability edema Sepsis, trauma, pulmonary aspiration

  23. Factors Predisposing to Aspiration • Lower esophageal sphincter • Upper esophageal sphincter • Protective airway reflexes • Apnea with laryngospasm • Coughing • Expiration • Spasmodic panting

  24. Post-esophagectomy status • An oro-gastric connection with significantly compromised esophageal sphincter function →increase risk of aspiration • Neck dissection and radiation therapy produce fibrotic change and distortion of neck anatomy →difficult intubation

  25. Pulmonary Aspiration • Aspiration pneumonitis Chemical injury caused by the inhalation of the sterile gastric contents • Aspiration pneumonia An infectious process caused by the inhalation of oropharyngeal secretions that are colonized by pathogenic bacteria

  26. Aspiration Pneumonitis • Severity associated with the volume and pH of aspirate, particulate food matters • Biphasic pattern of lung injury Phase I: Direct injury of alveolar- capillary interface Phase II: Acute inflammation

  27. Aspiration Pneumonitis • Syptoms and signs Gastric material in the oropharynx Wheezing Coughing Shortness of breath Cyanosis Pulmonary edema Hypotension Hypoxemia Rapid progression to ARDS

  28. Aspiration Pneumonia • Diagnosis a patient at risk for aspiration has radiographic evidence of an infiltrate in a characteristic bronchopulmonary segment • Risks stroke, neurologic dysphagia, disruption of the GE junction, anatomical abnormalities of the upper aerodigestive tract, elderly persons with poor oral care

  29. What We Can Do to Prevent Aspiration • Pre-anesthetic evaluation • NPO policy • Reducing gastric volume • Cricoid pressure • Airway device

  30. In post-esophagectomy patient • Carefully evaluated prior to intubation • Consider intubated in an upright postion • Subject to a low clinical threshold to proceed to fiberoptic intubation in the sitting position.

  31. The End Thank you

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