ERAS en Cirugía Pulmonar manejo intraoperatorio.pdf

Protocolo ERAS para cx pulmonar

1. ERAS PATHWAYS FOR
THORACIC SURGERY:
A CLINICAL GUIDE TO
INTRAOPERATIVE MANAGEMENT
Wanda M. Popescu, MD
Director Thoracic & Vascular Anesthesia Section
Professor of Anesthesiology

2. NO CONFLICT OF INTEREST

3. OBJECTIVES
•DiscussintraoperativemanagementgoalsforERATS
•Use of anxiolytics
•Protectivelung ventilation strategies
•Fluidmanagement
•Multimodal opioid sparring analgesia Next talk
•Antiemetictherapy
•Maintenance ofnormothermia
•Avoidance of tubes and drains

4. EurJ CardiothoracSurg2019;55:91

5. STUDYDESIGNCLINICAL OUTCOME
Van Haren
2018
Retrospective
2866 Pts
↓LOS, Pulm. complications, Afib
ND in readmission & mortality
Martin
2018
Retrospective
363 Pts↓ Cost & Opioid use
Rogers
2018
Prospective (No control)
422 Pts↓ LOS, morbidity
Brunelli
2017
Retrospective
600 PtsND in outcomes
Madani
2015
Retrospective
234 Pts
↓LOS, Complications
ND in readmission & mortality
VanHaren. J ThoracDis 2019;11:S612

6. •162 VATS pts vs 81 ERAS VATS pts
•62 thoracotomy pts vs 58 ERAS thoracotomy pts
•Median hospital cost
•VATS: $20169 vs. $ 14870 (p=0.0003)
•Thoracotomy: $41950 vs. $26089 (p<0.0001)
Martin. Ann ThoracSurg2018;105:1597

7. “ERAS protocols can be safely implemented, decrease
hospital length of stay and hold promise for decreasing
rates of perioperative complications.”
SeminThoracSurg2018

8. PATIENT’S ERAS JOURNEY

9. Improve Quality
Improve Safety
Increase Patient Satisfaction
Improve Costs
INTRAOPERATIVE
SurgicalTeam
Anesthesia Team
OR Nursing Staff
Regional Team
Pain Service
PREOPERATIVE
Preop. Anesthesia
Surgery ClinicStaff
POSTOPERATIVE
PACUNursing
SurgicalTeam
UnitNursing

10. ENHANCED RECOVERY AFTER
SURGERY

11. Premedication with benzodiazepines results in an OR 1.8 for
postoperative delirium
Billota. Minerva Anesthesiol2013;79:1066

12. Longer time to extubation in lorazepam group (17’ vs 12’ vs 13’)
Maurice-Szamburski. JAMA 2015;313:916
Lower rate of early cognitive recovery in lorazepam group

13. ERATS RECOMMENDATION
“Routine administration of sedatives to reduce anxiety preoperatively
should be avoided in order to hasten recovery.”
Evidence level: Moderate
Recommendation grade: Strong

14. VOLUTRAUMA & BAROTRAUMA
•2 groups:
•Historic Group: 553 pts no PLV
•Protocol Group: 558 pts PLV
•No PLV: TV 8-10 ml/Kg PBW, ±PEEP
•PLV: TV 5 ml/Kg PBW, PEEP 4-10, Recruitment
•ARDS 3.9% to 0.9%
•Atelectasis 8.8% to 5%
Licker. CritCare 2009;13:R41

15. •Largest difference in VTare seen in:
Female, short
•Use ARDSNetEquation for PBW:
•M: 50 + 0.905 (Height in cm –152.4)
•F: 45.5 + 0.905 (Height in cm –152.4)
Perdomo. Chest 2015;148:73

16. ACTUAL vs. PREDICTED BW
•Female, 152 cm
•Actual BW: 80 Kg
•PBW: 46 Kg
•No PLV 8 cc/kg:
640 cc vs. 368 cc
•PLV 5 cc/kg:
400 cc vs. 230 cc

17. •53 ptsPLV: TV 5 ml/Kg, PEEP 5 cmH2O
•48 ptsCV: TV 8 ml/Kg, no PEEP
PulmonaryComplications: 9.43% vs. 27.08%
Shen. JTCVS 2013;146:1267

18. •Retrospective, 2012-2014, 1019 pts OLV
•OLV results:
•43% pts receiving TV > 6 ml/Kg PBW
•19% pts receiving TV > 7 ml/Kg PBW
•7% pts receiving TV > 8 ml/Kg PBW
•Mean PEEP for cohort 4 cm H2O
•TV 1ml/Kg PBW 16% risk respiratory complications
•Low TV important but adequate PEEP needed
Blank. Anesthesiology 2016;124:1286

19. Recommended levels of V
Tand PEEP
DO NOT
decrease PPC
↑ Incidence of PPC: 12.4% to 18.6%
Incidence of PPC matched cohort: 15.6% vs. 16.1%
4550 patients
Submittedforpublication

20. INDIVIDUALIZED PEEP
AnesthAnalg2014;118:657Cdyn= TV/PIP-PEEP

21. RESULTS
TLVOLV
IND. PEEP
END
OLV
END
TLV
PaO2CONTROL436280231438
PaO2STUDY439301306*501
STATIC
COMPLIANCE
CONTROL53353349
STATIC
COMPLIANCE
STUDY4950*48*56

22. ERATS RECOMMENDATION
”Lung-protective strategies shouldbeusedduringone-lung ventilation”
VT4-6 cc/kg PBW
PEEP 5-10 cmH2O
ARM at beggingofOLV
Evidence level: Moderate
Recommendation grade: Strong

23. ATELECTASIS
•Operativelung:
•Purposefulfor surgicalexposure
•Ventilatedlung:
•Non-purposeful
•Mechanicalcompression
•Absorbtionatelectasiswhenusing100% FiO2

24. BLOOD FLOW IN NON-VENTILATED LUNG
HPV
CurrOpinAnesthesiol2017;30:42
Left lung blood flow(% of cardiac
output
)
Time (Minutes)

25. ATELECTOTRAUMA & REPERFUSION INJURY
•Normal lungmetabolism: 5% VO2max
•Bronchialarterysupply1%
•LungparenchymaobtainsO2fromdiffusion
•DuringOLV: lungisischemic
•Duringre-expansion: reperfusioninjury
•Result: Severeoxidativestress

26. No OLV1 h OLV1.5 h OLV2 h OLV
EurJ CardiothoracSurg2006:29:591

27. POSTOPERATIVE COMPLICATIONS
COMPLA(50 PTS)
NO OLV
B (30 PTS)
1 H OLV
C (30 PTS)
1.5 H OLV
D (22 PTS)
2 H OLV
ARDS4%3.3%3.3%9%*
ARRHYTHMIA32%27%37%59%*
PHTN0%0%0%9%*
EurJ CardiothoracSurg2006:29:591

28. PROTECTIVE LUNG VENTILATION 2019
•Physiologic TV: 4-6 ml/Kg PBW?
•Individualized PEEP
•Maximal Dynamic Compliance
•Alveolar recruitment maneuvers
•Low FiO2 during OLV?
•Low FiO2at re-expansion and TLV
•Decrease duration of OLV

29. •Evaluated 13 papers
•Liberal fluid protocols are associated with éincidence of ALI
•Causal relationship can’t be inferred
•Clinical recommendations:
•IntraopIVF: 1-2 ml/Kg/h
•Postopfluid balance: < 1.5 l
•Caution: Hypovolemia, AKI
Interactive Cardiovascular Thoracic Surery2012

30. •Observational study, 40 pts lung resection
•Targeting normovolemia: 1.5 ml/kg/h until oral hydration possible
•Protective lung ventilation
•Monitored using PiCCOtranspulmonary thermodilution: EVLW, CI
•Results:
•No increase in EVLW
•Improvement of CI
•AKI: 7.5% by AKIN and 2.5% by RIFFLE
J CardiothoracVacsAnesth2015;29:977

31. •139 ptsusingprotectivelungventilation
•161pulmonarycomplications
•4.3% mortality rate
•Fluidinfusionrateandsmokingwereindependentriskfactors

33. •RCT 3000 pts undergoing major abdominal surgery
•Liberal vs. restrictive fluid therapy in first 24 h
•Outcomes
•Primary: Disability free survival at 1 year
•Secondary: AKI @ 30 d, RRT @ 90 d, death, septic complications, SSI
•Results
•Primary: no difference
•AKI @ 30 d: 5% vs. 8.6% (p<0.001)
•Other outcomes: non-significant after adjustment
Myles. NEJM 2018;378:2263

34. ERATS RECOMMENDATION
“Very restrictive or liberal fluid regimes should be avoided in favor of
euvolemia. Intraoperative hypoperfusion can be avoided with the use
of vasopressors and a limited amount of fluid. Goal-directed therapy
and the use of non-invasive cardiac output monitors do not currently
appear to offer benefits to the thoracic surgical patient. Balanced
crystalloids are the intravenous fluid of choice.“
Euvolemic fluid management R: Strong / E: Moderate quality
Balanced crystalloids R: Strong / E: High quality

35. •446 minimally invasive lobectomies
•Retrospectivestudy
•Protectivelungventilation
•201 pulmonary complications in 176 pts
•Dividegroupintoquartilesbasedonfluidadministration
Wu.AnnThorcSurg2019;107:1663

36. 0
10
20
30
40
50
Quartile 1Quartile 2Quartile 3Quartile 4
Pulmonary Complications
9-12cc/kg/h
Wu.AnnThorcSurg2019;107:1663

37. YALE INTRAOPERATIVE PHASE
•Avoiding benzodiazepines
•Fluid management
•Preoperative clear liquids and carbohydrate load
•Intraoperative fluid use targeting euvolemiaor slightly restrictive
•Intraoperative use of balanced solutions
•Protective Lung ventilation
•4-6 cc/Kg PBW
•At least PEEP 5 cm H2O or higher
•PIP < 30 cm H2O
•Recruitment maneuver after institution of OLV
•Low FiO2at re-expansion

38. YALE INTRAOPERATIVE PHASE
•Postoperative Nausea/Vomiting management
•Assessment with ApfelScore
•Either oral preoperative or IV intraoperative ondansetron
•For high risk patients: add dexamethasone 8 mg, TIVA, avoid neostigmine
•Avoid sedating antiemetic drugs: droperidol, dimenhydrinate
•Antibiotic prophylaxis
•Cefazolin 2 or 3 g IV or
•Vancomycin 1 g IV within 1 h of incision
•Avoid hypothermia by active preop/intraoprewarming
•DVT prophylaxis: Venodyneboots, Heparin 5000 u SQ

39. CONCLUSION
•ERAS protocols in lung resection surgery can be beneficial
•Team communication is paramount importance
•Avoidsedatingmedications
•Aim towards euvolemia
•PLVparametersstillremainelusive
•Consider individualized PEEP and lower FiO2
•Constant auditing and optimization of the protocol

40. [email protected] YOU!