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A Case of Oxygen Desaturation at POR
R1 Minghui Hung
Department of Anesthsiology, NTUH
Case Summary
61-year-old male DM and HTN under regular
medication control Smoking: 2 PPD for more than 40
years Alcohol: socially
Case Summary
Lower third esophageal cancer status post CCRT and transhiatal esophagectomy with gastric tube reconstruction and jejunostomy in April, 2000
Complicated with mild leakage at cervical anastomosis site.
Case Summary
Mild dysphagia when eating solid food
Recurrent pus discharge from left neck wound with local erythematous swelling
Ventral hernia and direct type inguinal hernia
Induction Course
Pre-induction SpO2: 97%
Induction with fentanyl (100μg),
thiopental (250mg),
succinylcholine (100mg),
atracurium (30mg),
adjuncts with Rubinol (0.3mg),
2% Xylocaine (100mg)
Induction Course
Endotracheal intubation was performed with laryngoscope.
Direct visualization of oropharyngeal secretions around the glottis.
Peri-operative Course
Peri-operative course was uneventful except one episode of desaturation decreased to 95%.
Aminophylline 1 amp intravenous drip and Solu-medrol 2 vials was given.
Extubation after operation and sent to POR with Atrovent (1amp) and Bricanyl (1amp) inhalation.
At POR
Intra-operativeIVF: 1500ml; urine output: 900ml
Oxygen saturation decreased to 89-90% when arriving POR
Tachypnea and dyspnea with restless
Bilateral inspiratory rales and crackles was noted
No wheezing
At POR
Oxygen saturation decreased to 75%, Ambu bag was used and SpO2 return to around 90%
ABG showed no obvious acid-base disorder, nor electrolyte imbalance, but hypoxemia was noted
Arterial Blood Gas Analysis pH: 7.350 PCO2: 39.8 mmHg PO2: 53.3 mmHg Na: 141 mM, K: 3.8 mM,
Cl: 113 mM, Ca: 1.02 mM Glucose: 192 mg/dL Hb: 15.2 g/dL HCO3: 22.1 mM BE: -3.7 mM O2Sat: 85.6% Anion Gap: 10 Osmolarity: 282 mOsm
At POR
Demerol 25mg for analgesia Lasix 1 amp was used for diuresis Portable CxR Complete EKG
Chest X-ray
CxR at POR Previous CxR
Complete EKG
CK: 85 U/L CK/MB:8.9 U/L Troponin I: 0 ng/ml
At POR
Blood pressure dropped to 75/48 mmHg, Dopamine set 10 ml/hr was used and emergent intubation was performed at POR
Sent to ICU with stable vital signs
Intensive Care Unit
Transthoracic cardiography – good LV contractility– no RA or RV dilatation – hypovolemia
Intensive Care Unit
At ICU, empirical antibiotics• Cefmetazone 2vials q8h• Gentamicin 1vial q12h
Inotropic agents• Dopamine• Levophed
Fresh frozen plasm transfusion Inhalation brochodilators Mechanical ventilator support (PEEP)
Intensive Care Unit
Cardiac enzyme
CK CK/MB Troponin I
10/24 85.0 8.9 0
10/25 340.0 12.3 0
408.0 15.9 0
398.0 14.8 0
10/26 334.0 14.2 0
Intensive Care Unit
Hemogram
10/21 10/24 10/25 10/27
WBC 7640 8820 13960 7910
Hb 14.4 15.1 13.0 10.8
PLT 179K 177K 166K 137K
Intensive Care Unit
Coagulation study
10/21 10/24 10/25 10/28
PT 11.6/11.2 12.8/11.9 13.8/11.3 11.1/10.8
PTT 37.5/36.2 32.8/35.4 41.9/35.2 43.8/36.0
D-Dimer 1.76
Intensive Care Unit
Blood chemistry study
10/21 10/24 10/26 10/28
Alb 4.1 3.07 3.7
T-Bil 0.3 1.01 0.9
AST 21.0 20.0 23.0
BUN 13.9 10.4 23.8 12.3
CRE 0.7 0.68 0.64 0.6
Intensive Care Unit
Inotropic agents was titrated and DC at day 2
Ventilator weaning and extubation at day 3
No more dyspnea Bilateral rales and crackles impro
ved except RLL Back to general ward on day 5
What happened?→Pulmonary Edema
Hemodynamic edemaLV failure, mitral stenosisLeft-to-right cardiac shunt, fluid overload, severe anemia
Permeability edemaSepsis, trauma, pulmonary aspi
ration
Factors Predisposing to Aspiration Lower esophageal sphincter Upper esophageal sphincter Protective airway reflexes
• Apnea with laryngospasm• Coughing• Expiration• Spasmodic panting
Post-esophagectomy status
An oro-gastric connection with significantly compromised esophageal sphincter function
→increase risk of aspiration
Neck dissection and radiation therapy produce fibrotic change and distortion of neck anatomy
→difficult intubation
Pulmonary Aspiration
Aspiration pneumonitisChemical injury caused by the inhalation of the sterile gastric contents
Aspiration pneumoniaAn infectious process caused by the inhalation of oropharyngeal secretion
s that are colonized by pathogenic bacteria
Aspiration Pneumonitis
Severity associated with the volume and pH of aspirate, particulate food matters
Biphasic pattern of lung injuryPhase I: Direct injury of alveolar-
capillary interfacePhase II: Acute inflammation
Aspiration Pneumonitis
Syptoms and signsGastric material in the oropharynxWheezingCoughingShortness of breathCyanosisPulmonary edemaHypotensionHypoxemiaRapid progression to ARDS
Aspiration Pneumonia Diagnosis
a patient at risk for aspiration has radiographic evidence of an infiltrate in a characteristic bronchopulmonary segment
Risksstroke, neurologic dysphagia, disruption of the GE junction, anatomical abnormalities of the upper aerodigestive tract, elderly persons with poor oral care
What We Can Do to Prevent Aspiration Pre-anesthetic evaluation NPO policy Reducing gastric volume Cricoid pressure Airway device
In post-esophagectomy patient
Carefully evaluated prior to intubation
Consider intubated in an upright postion
Subject to a low clinical threshold to proceed to fiberoptic intubation in the sitting position.
The EndThank you