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Life in the Fast Lane • LITFL • Medical Blog

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Exam | FCICM | CICM SAQ 2014.1 Q22

CICM SAQ 2014.1 Q22

by Chris Nickson, Last updated May 18, 2016

Questions

A 62-year-old male is admitted to the ICU post-operatively having undergone a transthoracic oesophagectomy for squamous cell carcinoma of the oesophagus. The patient was extubated at the end of the operation but requires re-intubation two days post-surgery due to respiratory failure.

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.

Answers

a)

Answer and interpretation

  • 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.
  • Chylothorax.
  • Myocardial ischaemia.
  • Cardiac failure.
  • Weakness due to pre-existing malnutrition.

b)

Answer and interpretation

Pros

  • 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

Cons

  • Oesophageal anastomosis might be compromised and oesophageal leak is a devastating complication
  • Many of these patients are at high risk of aspiration

c)

Answer and interpretation

  • 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

CICM Fellowship Short Answer Questions (SAQ)

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Filed Under: FCICM Fellowship Tagged With: anastomotic leak, non-invasive ventilation (NIV), oesophagectomy, respiratory failure

About Chris Nickson

FCICM FACEM BSc(Hons) BHB MBChB MClinEpid(ClinTox) DipPaeds DTM&H GCertClinSim

Chris is an Intensivist at the Alfred ICU in Melbourne and is an Adjunct Clinical Associate Professor at Monash University. He is also the Innovation Lead for the Australian Centre for Health Innovation and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He has a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia's Northern Territory, Perth and Melbourne. He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education. He coordinates the Alfred ICU's education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the 'Critically Ill Airway' course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of Lifeinthefastlane.com, the RAGE podcast, the Resuscitology course, and the SMACC conference. His one great achievement is being the father of two amazing children. On Twitter, he is @precordialthump.

Reader Interactions

Comments

  1. mads astvad says

    September 1, 2014 at 12:55 pm

    Hi Chris
    Great stuff as usual, but I feel maybe the opening question describes different patient to the saq’s given, i.e. no operative condition mentioned. Supposedly post oesophagectomy?
    On that note, would u use SDD? That is current practice in my unit for anastomosis leak, but haven’t chased evidence base recently.
    Cheers, Mads

    Reply
    • Chris Nickson says

      September 1, 2014 at 1:14 pm

      Thanks Mads
      The question had the wrong stem – have now corrected
      SDD is not used in Australia – largely due to concerns about external validity and the potential impact on the microbial ecology of Australasian ICUs.
      Will see what happens with the SUDDICU trial…
      Cheers
      Chris

      Reply
  2. mads astvad says

    September 2, 2014 at 12:49 pm

    Thx Chris. Was not aware of SUDDICU trial. Looks like might provide further answers on value of prophylactic SDD use in general, but maybe not specifically in proven upper GI anastamotic leak. Always more questions than answers, eh.

    Chris, this is a bit pedantic, but doesn’t seem the correction of stem took effect. I’m at url http://lifeinthefastlane.com/cicm-saq-2014-1-q22/
    Some box needs a tick?

    Reply
    • Chris Nickson says

      September 2, 2014 at 1:43 pm

      Sorry Mads – this post seems to have a life of its own.
      SDD certainly didn’t make the CICM model answer for this one – however it does seem to be supported by available European evidence. Still probably concerns about external vailidity and lack of a definitive trial. SDD just doesn’t seem popular in the Antipodes…
      C

      Reply

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