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.
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)
- 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)
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)
- 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
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
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
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?
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