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LUISA FERNANDA SANTAMARIA DIAZ
RESIDENTE ANESTESIOLOGIA
UNIVERSIDAD DEL ROSARIO
FUNDACION ABOOD SHAIO
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VALORACION PREOPERATORIA Funcion mecanica pulmonar
Funcion parenquima pulmonar
Reserva cardiopulmonar
Espirometria
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OBJETIVOSEvaluación patología(s) de base
Preparación prequirúrgica
Inoperabilidad?
Riesgo quirúrgico
Manejo intraoperatorio
Considerar complicaciones postoperatorias
Bernstein W.,Deshpande S.Preoperative avaluationfor thoracic surgery.Seminars in cardiothoracic and vascular anesthesia, June 2008;12(2):109-121
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1. MECANICA PULMONAR
PPOVEF1 < 40% riesgo aumentado de complicaciones
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2. PARENQUIMA PULMONAR DLCO
< 40%: COMPLICACIONES POSTOPERATORIAS
<20% INOPERABILIDAD
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3. FUNCION CARDIOPULMONAR Prueba ergometrica
Consumo maximo de oxigeno
Ascenso escalones: >5: >20mL/Kg/min
2 escalones: 12mL/Kg/min: alto riesgo
Caminata 6 minutos: 610m= 15mL/Kg/min
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VALORACION PREOPERATORIA Historia clínica
Clase funcional
Comorbilidades
Tabaquismo
Examen físico completo
Paraclinicos
Bernstein W.,Deshpande S.Preoperative avaluationfor thoracic surgery.Seminars in cardiothoracic and vascular anesthesia, June 2008;12(2):109-121
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COMPLICACIONES POSTOPERATORIAS
Atelectasias, neumonía, falla respiratoria 15 – 20%
Mortalidad 3 – 4%
Complicaciones cardiacas 10 – 15%
Bernstein W.,Deshpande S.Preoperative avaluationfor thoracic surgery.Seminars in cardiothoracic and vascular anesthesia, June 2008;12(2):109-121
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DISNEA
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FACTORES DE RIESGO Tabaquismo
ASA
Comorbilidades
EPOC
Asma
Tipo de cirugía
Edad > 70
Estado nutricionalBernstein W.,Deshpande S.Preoperative avaluationfor thoracic surgery.Seminars in cardiothoracic and vascular anesthesia, June 2008;12(2):109-121
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TIPO DE CIRUGIA
Resecciones infralobares 0,8 – 1,4%
Lobectomías 1,2 – 4,4%
Neumonectomias 3,1 – 16,7%
Bernstein W.,Deshpande S.Preoperative avaluationfor thoracic surgery.Seminars in cardiothoracic and vascular anesthesia, June 2008;12(2):109-121
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AUMENTO MORBILIDAD POSTOPERATORIA
• VEF1<2L o 60% predicho
• DLCO<50%
• FEF 25-75 < 1.6L
NEUMONECTOMIA
• VEF1< 1L
• FEF 25-75<0.6L
• DLCO <50%
LOBECTOMIA
• VEF1<0.6L
• DLCO <50%SEGMENTECTOMIA
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COMORBILIDADESEnfermedad cardiovascular
Enfermedad renal
Enfermedad pulmonar
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1. ENFERMEDAD CARDIOVASCULARSegunda causa de morbimortalidad
Isquemia 5% (tabaquismo,
Arritmias 30-50% (60% FA)
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2. ENFERMEDAD RENAL
Disfuncion renal perioperatoria eleva la mortalidad (19%)
Factores de riesgo (disfuncion renal previa, diureticos, neumonectomia, infeccionpostoperatoria, transfusiones)
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3. ENFERMEDAD PILMONAR CRONICA
I: VEF1>50%
II:VEF1 35-50%
III: VEF1<35%
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Gasimetria arterial
SAHOS?
Hipertension pulmonar?
Disfuncion ventricular derecha (50%)
Bulas
Broncoespasmo
Atelectasias
Infeccion bacteriana
Edema pulmonar
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CA PULMONAR
MASA
METABOLICO
METASTASIS
MEDICAMENTOS
Bolliger C.,Colice G., Griffin J., Keenan R., Shafazan S.Physiologic evaluation of the patient with lung cancer being considered for resectionalsurgery.Chest 2007, 132:161-177
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RX TORAX Posición de la tráquea
Masa mediastinal
Derrames pleurales
Cardiomegalia
Bulas
Niveles hidroaereos
Infiltrados
Consolidación
Atelectasias
Normal (10%) Bernstein W.,Deshpande S.Preoperative avaluationfor thoracic surgery.Seminars in cardiothoracic and vascular anesthesia, June 2008;12(2):109-121
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OXIGENACIONPulsoximetria
Desaturacion 1-10% con FIO2 1
Gasimetria arterial basal
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PULSOXIMETRIA 4% exactitud en Sa02< 70%
Correlación clínica
Ubicación del sensor
Mala perfusión periférica
Alteración flujo arterial
Pigmentación cutánea y ungueal
Movimiento
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SV02 Oxigenación tisular
Requiere catéter venoso central
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CAPNOGRAFIAMenos confiable en ventilación unipulmonar
Medida indirecta del gasto cardiaco
Monitor de flujo central y periférico
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Monitores de flujo centralVENTAJAS DESVENTAJAS
No tubo de muestreo Tracción TET
No obstrucción Quemaduras faciales
No presión Pesado y voluminoso
No vapor agua Posiciones inusuales
No contaminación Difícil esterilización
No demoraAumento de espacio
muerto
No dispersión Cordón eléctrico
Neonatos Sensor costoso
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Monitores de flujo lateral
VENTAJAS DESVENTAJAS
Fácil conexión Retardo en lectura
Pacientes despiertos Vapor de agua
Posiciones inusuales P en tubo de muestreo
EsterilizaciónDeformidad en
capnogramas
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LINEA ARTERIALCompresión mediastinal
Gasimetría seriada
Cambios hemodinamicos abruptos
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CATETER VENOSO CENTRAL 1962
PVC no confiable
Solo para neumonectomias?
Hemodialisis
Marcapaso transvenoso
Uso de vasoactivos
Muestras sanguíneas repetidas
Inadecuado acceso venoso periférico
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CATETER DE ARTERIA PULMONAR60-110cm
4-8Fr
Menos confiable??
Comorbilidades (cardiaca-renal)
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CONTRAINDICACIONESCoagulopatia
Válvula tricúspide protésica
Marcapaso endocardico
Inmunosupresión
Falta de entrenamiento del profesional
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NICO
PICCO
LIDCO
VIGILEO
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PICCO(PULSE INDUCED CONTOUR CARDIAC OUTPUT)
Termodilucion transpulmonar
Catéter venoso central
Catéter arterial
Mide volúmenes
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NICO Cambios en la relación de CO2 eliminado y CO2 de
final de espiración
Método de Fick
Solo en pacientes intubados
Error 37%
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LIDCO Termodilucion con Li
Acceso venoso central o periférico
Línea arterial
Datos cada 30 segundos
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ECOCARDIOGRAMA TRANSESOFAGICO
Equipo costoso e incomodo
Requiere experto
Patología esofágica coexistente
Riesgo de lesión laringo-faringea en pacientes pequeños
Evaluación función ventricular izquierda
Evaluación de los volúmenes, presiones y contractilidad derecha
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INDICACIONES DE ECOCARDIOGRAFIA TRANSESOFAGICA EN CIRUGIA DE TORAX
• Inestabilidad hemodinámica
• Efusión pleuralI• Compromiso tumoral de corazón y/o grandes vasos
• Tromboendarterectomia pulmonar
• Embolismo aéreo
• Trasplante pulmonar
• Trauma torácico
II
• Función ventricular derecha en resección pulmonarIII
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VIGILEO
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POSICION Desplazamiento del tubo
Lesion neurologica
Ventilacion dependiente aumenta 10%
Anestesiado cae 15%
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ESPIROMETRIA
Brusasco V.,et al.Standarisation of spirometry. Eur resp J 2005;26:319-338
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CONTRAINDICACIONES ABSOLUTAS:
Neumotórax
Angina inestable
Desprendimiento de retina
Hemoptisis activa
RELATIVAS
Traqueostomía
Fístula
Problemas orales
Hemiplejía facial
Náuseas por la boquilla
No comprender la maniobra (ancianos, niños)
Estado deteriorado
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NORMAL
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OBSTRUCCION FIJA
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EXTRATORACICA
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INTRATORACICA
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DLCO Enfermedad intersticial
Disnea de ejercicio aun con VEF1 normal
Bernstein W.,Deshpande S.Preoperative avaluationfor thoracic surgery.Seminars in cardiothoracic and vascular anesthesia, June 2008;12(2):109-121
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ESPIROMETRIA
VEF1
CVF
FEF 25.75
ASCENSO DE ESCALERAS
5 ESCALONES: VO2
20mL/Kg/min
2 ESCALONES: 12mL/Kg/min
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DLCO
Integridad membrana alveolo capilar
CAMINATA 6 MINUTOS
<2000Ft: <15mL/Kg/min
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VEF 1 POP
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FACTORES QUE AUMENTAN LA
MORBIMORTALIDAD
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FACTORES QUE AUMENTAN MORBIMORTALIDAD
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FASE PRUEBA ELEVADO RIESGO PREOPERATORIO
1. PRUEBA DE DOS PULMONES
•Gases arteriales•Espirometria•Volúmenes pulmonares
HipercapniaVEF1<50% CVFVEF1<2L
PRUEBA DE UN PULMON •Pruebas de desdoblamiento funcional izquierda-derecha
VEF1 POP previsible < 0,85L o flujo sanguíneo al pulmón enfermo > 70%
SIMULACION DE CONDICIONES POSTOPERATORIAS
•Oclusión bronquial•Oclusión arterial
PAP media > 40mmHgPaO2 < 45mm Hg
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CRITERIOS PARA RESECCION PULMONAR
PRUEBA NORMAL NEUMONECTOMIA LOBECTOMIA SEGMENTECTOMIA
VVM >100 L/min100 %
>70>55
40-70>40
40>35
CVF>50%100%
>2 L51-6441
FEV 100% 55-6530 - 40
40 -50 >40
FEV 25-75 2 L100%
>1.6>60
>0.6 – 1.6 >0.6
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ESTRATEGIAS PREQUIRURGICAS
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Optimizar manejo ambulatorio (B agonistas y corticoides)
No suspender medicacion habitual
www.cancer.gov
www.oncolink.uppen.edu
www.cancertrialshelp.org
Grant P.,Whyte R.Preoperative patient education in thoracic surgery.Thorac Surg Clin 2005;15:195-201
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REHABILITACION PULMONAR Terapia respiratoria profiláctica
Terapia física profiláctica
Suspender cigarrillo 2 meses antes
Higiene respiratoria