SANGUINAMENTO POSTOP

IN CHIR MAXILLO-FACCIALE

Dr. ssa C. Matellon, Dr. A. Cattaruzza

Scuola di Specializzazione di Anestesia e Rianimazione

Università degli Studi di Udine

Clinica di Anestesia e Rianimazione

(Dir. Prof. G. Della Rocca)

Tutor Dr. Vetrugno L.

Caso clinico

INTERVENTO:

MENTOPLASTICA DI INNALZAMENTO

Età 22 aa; 66 Kg ; 173 cm, BMI 22

Allergia alle penicilline

Caso clinico

VIE AEREE

Caso clinico

19/10/2013

• h 8.15 Induzione anestesia

• h 8.20 IRT

Cormack 1

Ora 8 9 10

FiO2 0.21 0.8 0.35 0.8-0.4-

Sevoflurane et 1.8-1.6 1.4 //

Midazolam mg 1

Rocuronio mg 35

Fentanyl mcg 100+100

Propofol mg 100+50

Remifentanil

mcg/kg/min

0.08 0.08 0.1 0.1 0.15 0.1 0.05-//

RA ml 3ml/kg/h

SpO2 99 99 99 99 99 99 100 100 100

EtCO2 38 36 36 36 36 34 33

AP mmHg 130/80 105/75 105/70 115/78 120/80 122/80 110/78 105/70 115/78

HR bpm 60 50 40 65 70 78 72 65 60 60

Modalità RS VCV RS

RR 12 14 14 13 13 13 13 13

Vol/min 470

Ppicco/PEEP 18/5 18/5 18/5 18/5 18/5 18/5

Caso clinico

Caso clinico

• h 10.10 Estubazione

• h 10.15 PACU

• h 11.30 Si dimette la pz in reparto.

Caso clinico

19/09/2013

• h 15:30 anestesista contattato dal chirurgo maxillo-

facciale:

comparsa di edema linguale, fonesi alterata, difficile

deglutizione, non dispnea.

Caso clinico

• h 15.45

- Allertamento S.O.

- Preparazione dei farmaci e dei presidi per la gestione delle

vie aeree

- Allertamento del secondo anestesista

- Richiesta del chirurgo maxillo-facciale in S.O.

INTUBAZIONE?

Intubazione in RS con FOB

Caso clinico

• h 16.00

- Lidocaina spray 10% nel cavo orale

- sevoflurane fino a 2.2 et

- propofol fino a max 6 mg/kg/h.

• h 16.20 IOT mediante guida fibrobroncoscopica.

Caso clinico

Ora 16 17 18

FiO2 0.21 0.8 0.4 0.8 1

Sevoflurane et 2.2 -1.9 1.6 //

Propofol mg/kg/h 6 // 5.5

Rocuronio mg 40

Alfentanil mg 1

Propofol mg 100

Remifentanil

mcg/kg/min

0.01 0.08-0.15 0.2 0.15 0.1 0.1 0.1 0.1

RA ml 3ml/mg/h

SpO2 99 100 100 100 100 100 100 100 100

EtCO2 38 36 38 38 36 37 36

AP mmHg 120/70 115/68 110/66 105/60 100/57 120/80 118/73 115/60 110/55

HR bpm 100 78 72 70 75 81 65 60 55

Modalità RS VCV ASS

RR 12 12 12 12 12 12 12

Vol/min 480

Ppicco/PEEP 14/5 14/5 14/5 14/5 14/5 14/5

Caso clinico

• h 18.00 Trasferimento in TI

• I POD: Regressione dell’edema linguale

ESTUBAZONE MEDIANTE SCAMBIATUBI

• II POD: Trasferimento in reparto

TEAM COMMUNICATION

MANAGEMENT DIFFICULT AIRWAY

AIRWAY COMPLICATION

Agenda

TEAM COMMUNICATION

MANAGEMENT DIFFICULT AIRWAY

AIRWAY COMPLICATION

Agenda

EFFICIENZA TEAMWORK

① Situational awarness

② Problem identification

③ Decision making

④ Workload distribution

⑤ Time management

⑥ Conflict resolution

TEAM COMMUNICATION

HUMAN ERROR

Acta Anesthesiol Scand 2005; 49:898-901

Team comunication in the operating room Davies J.M.

TEAM COMMUNICATION

MANAGEMENT DIFFICULT AIRWAY

AIRWAY COMPLICATION

Agenda

FACE MASK VENTILATION TRACHEAL INTUBATION

DIFFICULT AIRWAY MANAGEMENT

TRAINED ANESTHESIOLOGIST EXPERIENCES

DIFFICULT AIRWAY MANAGEMENT

o EVALUATION OF AIRWAY

o BASIC PREPARATION

o STRATEGIES FOR INTUBATION

o STRATEGIES FOR EXTUBATION

o FOLLOW UP CARE

DIFFICULT AIRWAY MANAGEMENT

o EVALUATION OF AIRWAY

Patient history

Airway examination

Diagnostic test

DIFFICULT AIRWAY MANAGEMENT

o BASIC PREPARATION

Informing patient

Portable strorage unit

Presence additional operator

Preoxygenation

DIFFICULT AIRWAY MANAGEMENT

Facemask ventilation Difficult Laryngoscopy

DIFFICULT AIRWAY MANAGEMENT

o STRATEGIES FOR INTUBATION AND VENTILATION

① Patient Cooperation

② Difficult mask ventilation

③ Difficult LMA placement

④ Difficult laryngoscopy

⑤ Difficult intubation

⑥ Difficult invasive access

Awake VS unconscious

NON invasive VS invasive

Video-assisted laryngoscopy

Preservation VS Ablation ventilation

DIFFICULT AIRWAY MANAGEMENT

o STRATEGIES FOR INTUBATION AND VENTILATION

PRIMARY APPROACH IDENTIFICATION to:

1.Awake intubation

2.Adeguate ventilation/difficult intubation

3.Cannot ventilate and intubate

ALTERNATIVE APPROACH to:

1. Uncooperative/pediatric patient

DIFFICULT AIRWAY MANAGEMENT

o STRATEGIES FOR INTUBATION AND VENTILATION

• Video assisted laryngoscopy

• Stylet/tube changers

• SGA for ventilation (LMA)

• SGA for intubation (ILMA)

• Fiberoptic-guided intubation

• Lighted stylets

DIFFICULT AIRWAY MANAGEMENT

o STRATEGIES FOR INTUBATION AND VENTILATION

Fiberoptic intubation

Video assisted laryngoscopy

Succeful 88-100%

Operator experience

Improve Cormack grade

Improve laryngeal view

Easier learning curve than FOB

DIFFICULT AIRWAY MANAGEMENT

o STRATEGIES FOR INTUBATION AND VENTILATION

FOB

VS

VIDEOLARINGOSCOPIO

NAP4, Major complications of airways management in the UK

Dr Tim Cook, Dr Nick Woodall and Dr Chris Frerk, March 2011

DIFFICULT AIRWAY MANAGEMENT

o STRATEGIES FOR INTUBATION AND VENTILATION

SGA for ventilation (LMA-ILMA)

Stylet/tube changers

Mantein/restore ventilation

Guide for intubation (ILMA)

Succeful 78-100%

Mucosal bleeding, sore throat

CONFIRM TRACHEAL INTUBATION WITH CAPNOGRAPHY/ETCO2

DIFFICULT AIRWAY MANAGEMENT

o EXTUBATION FAILURE

• UPPER AIRWAY OBSTRUCTION

• LARYNGOSPASM

• AIRWAY EDEMA

• POSTOPERATIVE BLEEDING

• PORC

• OPIOIDS SNC DEPRESSION

RISK FACTORS

OBESITY/OSA,

UPPER AIRWAY & CERVICAL

SPINE SURGERY,

OBSTETRICS.

DIFFICULT AIRWAY MANAGEMENT

TEAM COMMUNICATION

MANAGEMENT DIFFICULT AIRWAY

AIRWAY COMPLICATION

Agenda

DIFFICULT AIRWAY MANAGEMENT

o AIRWAY COMPLICATIONS

• FAILED AIRWAY MANAGEMENT

• HYPOXIA/BRAIN DAMAGE/DEATH

• PULMONARY ASPIRATION

• ESOPHAGEAL INTUBATION

• AIRWAY TRAUMA (major-minor)

Complications and failure of airway management, T. M. Cook* and S. R. MacDougall-Davis

British Journal of Anaesthesia 109 (S1): i68–i85 (2012)

Case report

…CONCLUSIONI:

RICONOSCIMENTO DEL PROBLEMA

RUOLO DELLA COMUNICAZIONE

ALGORITMO GESTIONALE