A 62-year-old male is admitted to the ICU post-operatively having undergone a transthoracic oesophagectomy for squamous cell carcinoma of the oesophagus. The patient was extubated at the end of the operation but requires re-intubation two days post-surgery due to respiratory failure.
a) List the likely underlying causes of respiratory failure specific to this clinical situation.
b) List the pros and cons of non-invasive ventilation in this clinical situation.
c) Briefly outline the principles of management of an anastomotic leak in this patient.
a)
Pre-existing COAD.
Diminished airway protection /Altered mental status.
Chronic aspiration due to impaired preoperative oesophageal function.
Postoperative aspiration due to recurrent laryngeal nerve compromise and/or inability to swallow.
Surgical complication including anastomotic breakdown or conduit ischaemia.
Postoperative pain.
Pleural effusion.
Chylothorax.
Myocardial ischaemia.
Cardiac failure.
Weakness due to pre-existing malnutrition.
b)
Pros
May reduce need for invasive ventilation
Decreased need for sedation as opposed to invasive ventilation
Many of the these patient have COAD – reduces work of breathing
May decrease risk of VAP
Cons
Oesophageal anastomosis might be compromised and oesophageal leak is a devastating complication
Many of these patients are at high risk of aspiration
c)
Assurance of adequate perfusion – maintain good MAP, maintain euvolemia, (avoid vasopressors if possible).
Adequate source control- all leaks must be adequately drained by re-operation or percutaneous drainage.
Cessation of contamination – Nil by mouth and well positioned NG tube with free drainage.
Appropriate nutritional support e.g. enteral feed via jejunostomy
Endoscopy to assess graft viability if concerned.
Consider oesophageal stent
Broad-spectrum antibiotics such as Tazocin and consider anti-fungals – Fluconazole after culture of blood and other secretions.
In general, cervical leaks can be managed with drainage of neck wound at the bedside, while thoracic leaks are likely to need open re-exploration and drainage