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A Case of Oxygen Desaturation at POR
R1 Minghui HungDepartment of Anesthsiology, NTUH
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Case Summary
61-year-old male DM and HTN under regular
medication control Smoking: 2 PPD for more than 40
years Alcohol: socially
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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.
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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
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Induction Course Pre-induction SpO2: 97% Induction with
fentanyl (100μg), thiopental (250mg), succinylcholine (100mg), atracurium (30mg),
adjuncts with Rubinol (0.3mg),2% Xylocaine (100mg)
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Induction Course
Endotracheal intubation was performed with laryngoscope.
Direct visualization of oropharyngeal secretions around the glottis.
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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.
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At POR
Intra-operativeIVF: 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
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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
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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
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At POR
Demerol 25mg for analgesia Lasix 1 amp was used for diuresis Portable CxR Complete EKG
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Chest X-ray
CxR at POR Previous CxR
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Complete EKG
CK: 85 U/L CK/MB:8.9 U/L Troponin I: 0 ng/ml
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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
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Intensive Care Unit
Transthoracic cardiography – good LV contractility– no RA or RV dilatation – hypovolemia
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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)
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Intensive Care Unit
Cardiac enzyme
CK CK/MB Troponin I
10/24 85.0 8.9 010/25 340.0 12.3 0
408.0 15.9 0398.0 14.8 0
10/26 334.0 14.2 0
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Intensive Care Unit
Hemogram
10/21 10/24 10/25 10/27WBC 7640 8820 13960 7910Hb 14.4 15.1 13.0 10.8
PLT 179K 177K 166K 137K
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Intensive Care Unit
Coagulation study
10/21 10/24 10/25 10/28PT 11.6/11.2 12.8/11.9 13.8/11.3 11.1/10.8
PTT 37.5/36.2 32.8/35.4 41.9/35.2 43.8/36.0D-Dimer 1.76
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Intensive Care Unit
Blood chemistry study
10/21 10/24 10/26 10/28Alb 4.1 3.07 3.7
T-Bil 0.3 1.01 0.9AST 21.0 20.0 23.0BUN 13.9 10.4 23.8 12.3CRE 0.7 0.68 0.64 0.6
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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 impro
ved except RLL Back to general ward on day 5
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What happened?→Pulmonary Edema
Hemodynamic edemaLV failure, mitral stenosisLeft-to-right cardiac shunt, fluid overload, severe anemia
Permeability edemaSepsis, trauma, pulmonary aspi
ration
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Factors Predisposing to Aspiration Lower esophageal sphincter Upper esophageal sphincter Protective airway reflexes
• Apnea with laryngospasm• Coughing• Expiration• Spasmodic panting
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Post-esophagectomy status
An oro-gastric connection with significantly compromised esophageal sphincter function
→increase risk of aspiration Neck dissection and radiation ther
apy produce fibrotic change and distortion of neck anatomy
→difficult intubation
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Pulmonary Aspiration
Aspiration pneumonitisChemical injury caused by the inhalation of the sterile gastric contents
Aspiration pneumoniaAn infectious process caused by the inhalation of oropharyngeal secretion
s that are colonized by pathogenic bacteria
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Aspiration Pneumonitis Severity associated with the
volume and pH of aspirate, particulate food matters
Biphasic pattern of lung injuryPhase I: Direct injury of alveolar-
capillary interfacePhase II: Acute inflammation
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Aspiration Pneumonitis Syptoms and signs
Gastric material in the oropharynxWheezingCoughingShortness of breathCyanosisPulmonary edemaHypotensionHypoxemiaRapid progression to ARDS
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Aspiration Pneumonia Diagnosis
a patient at risk for aspiration has radiographic evidence of an infiltrate in a characteristic bronchopulmonary segment
Risksstroke, neurologic dysphagia, disruption of the GE junction, anatomical abnormalities of the upper aerodigestive tract, elderly persons with poor oral care
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What We Can Do to Prevent Aspiration Pre-anesthetic evaluation NPO policy Reducing gastric volume Cricoid pressure Airway device
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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.
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The EndThank you