Özofagus Cerrahilerinde Postoperatif Yoğun Bakım
Özet
Özofagus cerrahisi, yüksek morbidite (%59) ve mortalite riskleri (%2.4-%4.5) barındıran kompleks operasyonlardır. Postoperatif süreçte mortalitenin temel nedeni, özellikle vakaların %16-27'sinde görülen ve ölümlerin %55'inden sorumlu olan pulmoner komplikasyonlardır. Yoğun bakım takibinde, hasta yönetimini standardize etmek amacıyla Feeding (Beslenme), Analgesia (Analjezi), Sedation (Sedasyon), Thromboembolic prophylaxis (Tromboemboli profilaksisi), Head of bed elevation (Yatak başının yükseltilmesi), Stress Ulcer prophylaxis (Ülser profilaksisi), Glucose control (Glukoz kontrolü) adımlarını içeren FAST HUGS BID kodlaması sıklıkla tercih edilmektedir. Operasyon sonrası hastaların agresif şekilde ısıtılması ölümcül üçlü olan hipotermi, asidoz ve koagülopatiyi önlemek açısından kritiktir. Ağrı yönetiminde, torasik epidural anesteziye kıyasla daha az komplikasyon riski taşıyan paravertebral sinir blokajı ön plana çıkmaktadır. Tromboemboli profilaksisinde mekanik yöntemler ve DMAH gibi farmakolojik ajanlar kullanılırken, heparin kullanımında HİT riski göz önünde bulundurulmalıdır. Solunum fizyoterapisi, preoperatif rehabilitasyon, erken enteral beslenme ve uygun sıvı yönetimi pulmoner riskleri azaltmaktadır. Ayrıca aritmi takibi için EKG ve hemodinamik monitörizasyon, nadir fakat ölümcül olan akut kardiyak herniasyon durumlarında ise acil cerrahi müdahale gereklidir. COVID-19 pandemisi ise kanser tedavilerinin zamanlamasını ve klinik süreçlerini daha karmaşık hale getirmiştir.
Esophageal surgery constitutes complex operations carrying high morbidity (59%) and mortality risks (2.4%-4.5%). The primary cause of mortality in the postoperative period is pulmonary complications, which are observed in 16%-27% of cases and are responsible for 55% of hospital deaths. In intensive care follow-up, the FAST HUGS BID mnemonic—encompassing Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head of bed elevation, Stress Ulcer prophylaxis, and Glucose control—is frequently preferred to standardize patient management. Aggressive warming of patients postoperatively is critical to prevent the lethal triad of hypothermia, acidosis, and coagulopathy. In pain management, paravertebral nerve blockade stands out due to its lower risk of complications compared to thoracic epidural anesthesia. While mechanical methods and pharmacological agents like LMWH are utilized for thromboembolism prophylaxis, the risk of HIT must be considered during heparin use. Respiratory physiotherapy, preoperative rehabilitation, early enteral nutrition, and appropriate fluid management reduce pulmonary risks. Furthermore, ECG and hemodynamic monitoring are necessary for arrhythmia surveillance, whereas immediate surgical intervention is required in cases of rare but fatal acute cardiac herniation. Lastly, the COVID-19 pandemic has further complicated the timing and clinical processes of cancer treatments.
Referanslar
Low DE, Kuppusamy MK, Alderson D, Cecconello I, Chang AC, Darling G, et al. Benchmarking complications associated with esophagectomy. Ann Surg. 2019;269:291–8.
Walters DM, McMurry TL, Isbell JM, Stukenborg GJ, Kozower BD. Understanding mortality as a quality indicator after esophagectomy. Ann Thorac Surg. 2014 Aug;98(2):506-11; discussion 511-2. doi: 10.1016/j.athoracsur.2014.03.041. Epub 2014 May 17. PMID: 24841544.
Law S. Wong K.H. Kwok K.F. Chu K.M. Wong J. Predictive factors for postoperative pulmonary complications and mortality after esophagectomy for cancer. Ann Surg. 2004; 240: 791-800
Avendano C.E. Flume P.A. Silvestri G.A. King L.B. Reed C.E. Pulmonary complications after esophagectomy. Ann Thorac Surg. 2002; 73: 922-926
Vincent JL. Give your patient a fast hug (at least) once a day. Crit Care Med. 2005 Jun;33(6):1225-9. doi: 10.1097/01.ccm.0000165962.16682.46. PMID: 15942334.
Vincent WR 3rd, Hatton KW. Critically ill patients need “FAST HUGS BID” (an updated mnemonic). Crit Care Med 2009;37:2326-7.
Chinkungwa M. Extend ‘FAST HUG’ with ‘FAITH’ JICS 2010;11:69-70
Wolberg AS, Meng ZH, Monroe DM 3rd, Hoffman M. A systematic evaluation of the effect of temperature on coagulation enzyme activity and platelet function. J Trauma. 2004 Jun;56(6):1221-8. doi: 10.1097/01.ta.0000064328.97941.fc. PMID: 15211129.
Journal of Parenteral and EnteralNutritionVolume 40 Number 2 February 2016 159–211© 2016 American Societyfor Parenteral and Enteral Nutrition and Society of Critical Care MedicineDOI: 10.117
Journal of Parenteral and EnteralNutritionVolume 40 Number 2 February 2016 159–211© 2016 American Societyfor Parenteral and Enteral Nutrition and Society of Critical Care Medicine
Kaaki S, Grigor EJM, Maziak DE, Seely AJE. Early oral intake and early removal of nasogastric tube post-esophagectomy: A systematic review and meta-analysis. Cancer Rep (Hoboken). 2022 May;5(5):e1538. doi: 10.1002/cnr2.1538. Epub 2021 Sep 7. PMID: 34494402; PMCID: PMC9124520. Fujita T, Daiko H,
Nishimura M (2012) Early Enteral Nutrition Reduces The Rate Of Life-Threatening Complications After Thoracic Esophagectomy in Patients With Esophageal Cancer. Eur Surg Res 48:79–84
Mazaki T, Ebisawa K (2008) Enteral versus parenteral nutrition after gastrointestinal surgery: a systematic review and metaanalysis of randomized controlled trials in the English literature. J Gastrointest Surg 12:739–755
Low, D.E., Allum, W., De Manzoni, G., Giovanni De Manzoni. , Lorenzo Ferri. , et al. Guidelines for Perioperative Care in Esophagectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations. World J Surg 43, 299–330 (2019).
Sun HB, Li Y, Liu XB, Rui-Xiang Zhang , Zong-Fei Wang , Toni Lerut et al. Early Oral Feeding Following McKeown Minimally Invasive Esophagectomy: An Open-label, Randomized, Controlled, Noninferiority Trial. Ann Surg 2018; 267:435.
Phillips DM. JCAHO Pain Management Standards Are Unveiled. JAMA 2000;284:428-9.
Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D, Wittbrodt ET, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002;30:119-41.
Baidya DK, Khanna P, Maitra S (2014) Analgesic efficacy and safety of thoracic paravertebral and epidural analgesia for thoracic surgery: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 18:626–635
Rasheed AM, Amirah MF, Abdallah M, P J P, Issa M, Alharthy A. Ramsay Sedation Scale and Richmond Agitation Sedation Scale: A Cross-sectional Study. Dimens Crit Care Nurs. 2019 Mar/Apr;38(2):90-95. doi: 10.1097/DCC.0000000000000346. PMID: 30702478.
Senoglu N, Köse I, Zincircioğlu Ç, Erbay R.H. Yoğun Bakımla Hızlı Kucaklaşma (Fast Hugs) Türk Yoğun Bakım Derneği Dergisi (2014)12: 72-81
Ng KT, Shubash CJ, Chong JS. The effect of dexmedetomidine on delirium and agitation in patients in intensive care: systematic review and meta-analysis with trial sequential analysis. Anaesthesia. 2019 Mar;74(3):380-392. doi: 10.1111/anae.14472. Epub 2018 Oct 27. PMID: 30367689.
Mantziari S, Gronnier C, Pasquer A, Johan Gagnière , Jérémie Théreaux , Nicolas Demartines , et al (2016) Incidence and risk factors related to symptomatic venous thromboembolic events after esophagectomy for cancer. Ann Thorac Surg 102:979–984
Geerts W, Selby R. Prevention of venous thromboembolism in the ICU. Chest 2003;124:357-63.
Morris RJ, Woodcock JP (2010) Intermittent pneumatic compression or graduated compression stockings for deep vein thrombosis prophylaxis? A systematic review of direct clinical comparisons. Ann Surg 251:393–396
Akl EA, Labedi N, Terrenato I, Barba M, Sperati F, Sempos EV, et al. (2011) Low molecular weight heparin versus unfractionated heparin for perioperative thromboprophylaxis in patients with cancer. Cochrane Database Syst Rev CD009447
Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ; American College of Chest Physicians. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. 8th ed. Chest 2008;133(6 Suppl):454S-545S.
Warkentin TE, Greinacher A, Koster A, Lincoff AM; American College of Chest Physicians. Treatment and prevention of heparin-induced thrombocytopenia: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008;133(6 Suppl):340S-80S.
Dietmer F. Thrombosis prophylaxis in critically ill patients. Wien Med Wochenschr 2011;161 (3-4):68-72.
Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ. American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141(2 Suppl):7S-47S.
Nagler M, Haslauer M, Wuillemin WA. Fondaparinux - data on efficacy and safety in special situations. Thromb Res 2012;129(4):407-17.
Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogué S, Ferrer M. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: A randomised trial. Lancet 1999;354:1851-8.
Ye Z, Reintam Blaser A, Lytvyn L, Wang Y, Guyatt G H, Mikita J S et al. Gastrointestinal bleeding prophylaxis for critically ill patient: a clinical practice guideline BMJ 2020; 368:16722 doi:10.1136/bmj.16722.
NICE-SUGAR Study Investigators, Finfer S, Chittock DR, Su SY, Blair D, Foster D, Dhingra V, at al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009 Mar 26;360(13):1283-97. doi: 10.1056/NEJMoa0810625. Epub 2009 Mar 24. PMID: 19318384.
Short V, Herbert G, Perry R, Rachel Perry, Charlotte Atkinson, Andrew R Ness, at al. (2015) Chewing gum for postoperative recovery of gastrointestinal function. Cochrane Database Syst Rev CD006506 231.
Bundgaard-Nielsen M, Holte K, Secher NH, H Kehlet. (2007) Monitoring of peri-operative fluid administration by individualized goal-directed therapy. Acta Anaesthesiol Scand 51:331–340
Jorgensen H, Wetterslev J, Moiniche S , J B Dahl. (2000) Epidural local anaesthetics versus opioid-based analgesic regimens on postoperative gastrointestinal paralysis, PONV and pain after abdominal surgery. Cochrane Database Syst Rev CD001893
Wittenstein J, Ball L, Pelosi P, Gama de Abreu M. High-flow nasal cannula oxygen therapy in patients undergoing thoracic surgery: current evidence and practice. Curr Opin Anaesthesiol 2019; 32:44.
Michelet P, D'Journo XB, Seinaye F, J M Forel, L Papazian, P Thomas. Non-invasive ventilation for treatment of postoperative respiratory failure after oesophagectomy. Br J Surg 2009; 96:54.
Acıbadem Üniversitesi Sağlık Bilimleri Dergisi Özofajektomi Sonrası Pulmoner Komplikasyon Gelişen Olgular ve Tedavi Yaklaşımları A Mehmet Erdem Çakmak , Hayriye Cankar Dal , Derya Ademoğlu , Serdar Yamanyar , Büşra Tezcan , Dilek Kazancı at al. Özofajektomi Sonrası Pulmoner Komplikasyon Gelişen Olgular ve Tedavi Yaklaşımları D 2019 J Acıbadem Üniversitesi Sağlık Bilimleri Dergisi P 1309-470X-1309-5994 V N 2 R U
Minnella EM, Awasthi R, Loiselle SE, Ramanakumar V Agnihotram , Lorenzo E Ferri , Francesco Carli. Effect of Exercise and Nutrition Prehabilitation on Functional Capacity in Esophagogastric Cancer Surgery: A Randomized Clinical Trial. JAMA Surg 2018; 153:1081.
Low DE, Allum W, Giovanni De Manzoni , Lorenzo Ferri , Arul Immanuel , MadhanKumar Kuppusamy , at al. Guidelines for Perioperative Care in Esophagectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations. World J Surg 2019; 43:299
Chu L, Fuller A. Manual of clinical anesthesiology. 1st edition. Philedelphia: Lippincott Williams & Wilkins; 2012. p.56.
Marik PE. Pulmonary artery catheterization and esophageal doppler monitoring in the ICU. Chest 1999;116(4):1085-91.
Munis JR, Bhatia S, Lozada LJ. Peripheral venous pressure as a hemodynamic variable in neurosurgical patients. Anesth Analg 2001; 92(1):172-9.
Marik PE, Cavallazzi R, Vasu T, Hirani A. Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature. Crit Care Med 2009;37(9):2642-7.
Nagler J, Krauss B. Capnography: a valuable tool for airway management. Emerg Med Clin North Am. 2008 Nov;26(4):881-97, vii.
Ekemen S, Özen E. Standard and Current Practices in Intensive Care Monitoring. Turkiye Klinikleri J Intensive Care-Special Topics. 2015;1(3):1-9
Baisi A, Ugo Cioffi MD, Mario Nosotti MD, Matilde De Simone MD, Lorenzo Rosso MD, Luigi Santambrogio MD : J Thorac Cardiovasc Surg 123:1206, 2002.
Rippey JC, Sudhakar Rao and Daniel Fatovich: CJEM 6:126, 2004.
Mehanna, Mayssoun J. MD*; Israel, Gary M. MD*; Katigbak, Mario MD†; Rubinowitz, Ami N. MD* J Thorac Imaging 22:280, 2007.
David J. Sugarbaker MDa, Michael T. Jaklitsch MDa, Raphael Bueno MDa, William Richards PhDa, Jeanne Lukanich MDa, Steven J.Mentzer MDa, et al: J Thorac Cardiovasc Surg 128:138, 2004.
Orringer MB, Marshall B, Iannettoni MD. Transhiatal esophagectomy: clinical experience and refinements. Ann Surg 1999; 230:392.
Mathisen DJ, Grillo HC, Wilkins EW Jr, A D Hilgenberg. Transthoracic esophagectomy: a safe approach to carcinoma of the esophagus. Ann Thorac Surg 1988; 45:137.
Ellis FH Jr, Heatley GJ, Krasna MJ, W A Williamson, K Balogh. Esophagogastrectomy for carcinoma of the esophagus and cardia: a comparison of findings and results after standard resection in three consecutive eight-year intervals with improved staging criteria. J Thorac Cardiovasc Surg 1997; 113:836.
Orringer MB, Marshall B, Chang AC, Julia Lee, Allan Pickens, Christine L Lau. Two thousand transhiatal esophagectomies: changing trends, lessons learned. Ann Surg 2007; 246:363
Atkins BZ, Shah AS, Hutcheson KA, Jennifer H Mangum, Theodore N Pappas, David H Harpole Jr, et al. Reducing hospital morbidity and mortality following esophagectomy. Ann Thorac Surg 2004; 78:1170.
Gockel I, Kneist W, Keilmann A, Junginger T. Recurrent laryngeal nerve paralysis (RLNP) following esophagectomy for carcinoma. Eur J Surg Oncol 2005; 31:277.
