a) List the likely underlying causes of respiratory failure specific to this clinical situation
b) List the pros and cons of non-invasive ventilation in this clinical situation.
c) Briefly outline the principles of management of an anastomotic leak in this patient.
- Pre-existing COAD.
- Diminished airway protection /Altered mental status.
- Chronic aspiration due to impaired preoperative oesophageal function.
- Postoperative aspiration due to recurrent laryngeal nerve compromise and/or inability to swallow.
- Surgical complication including anastomotic breakdown or conduit ischaemia.
- Postoperative pain.
- Pleural effusion.
- Myocardial ischaemia.
- Cardiac failure.
- Weakness due to pre-existing malnutrition.
- May reduce need for invasive ventilation
- Decreased need for sedation as opposed to invasive ventilation
- Many of the these patient have COAD – reduces work of breathing
- May decrease risk of VAP
- Oesophageal anastomosis might be compromised and oesophageal leak is a devastating complication
- Many of these patients are at high risk of aspiration
- Assurance of adequate perfusion – maintain good MAP, maintain euvolemia, (avoid vasopressors if possible).
- Adequate source control- all leaks must be adequately drained by re-operation or percutaneous drainage.
- Cessation of contamination – Nil by mouth and well positioned NG tube with free drainage.
- Appropriate nutritional support e.g. enteral feed via jejunostomy
- Endoscopy to assess graft viability if concerned.
- Consider oesophageal stent
- Broad-spectrum antibiotics such as Tazocin and consider anti-fungals – Fluconazole after culture of blood and other secretions.
- In general, cervical leaks can be managed with drainage of neck wound at the bedside, while thoracic leaks are likely to need open re-exploration and drainage
Pass rate: 34%
Highest mark: 8.o