Nationaal nascholingscongres anesthesiologie

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1 Nationaal nascholingscongres anesthesiologie Thema: Longen 9 november 2016

2 Longresectie: kun je leven op één kwab? Dr Anco Boonstra longarts VUMC, Amsterdam Dr Boonstra or his employer VUMC has or had financial relationships with companies including but not limited to: Actelion, Pfizer, Tefa, Sun Pharma, Bayer, United Therapeutics, Therabel, Ferrer, Boehringer Ingelheim, GSK, Mondobiotech. In addition to being an investigator in trials involving these companies relationships include financial reimbursement for consultancy service and membership of scientific advisory boards. All payments from 2012 larger than 500 Eu can be found on under number

3 Na deze presentatie Kent u de hoofd items van long-ergometrie Kent u het algoritme om longresectie in te schatten

4 Kun je leven op 1 kwab? Rust VO2 240ml/min Max VO ml/min Is dan 1/10 de long voldoende?

5 Kun je leven op 1 kwab? Rust CO 5 l/min Max CO 25 l/min Is dan 1/5 de long voldoende? Gaat de druk omhoog (wet van Ohm)

6 Hoge flow/ druk = model voor Pulmonale Hypertensie

7 Kun je leven op 1 kwab? Toename van invloed van dode ruimte Vd = 150 ml pco2 = VCO2/VA x K Co-assistent

8 Waar gaat het om postoperatief leven Is inspannen

9 Direct gemeten waarden bij ergometrie VO2 VCO2 Adem volume (VE) Hartfrequentie Bloeddruk Wattage Saturatie In en expiratie tijd Expiratoire pco2 en po2 (ETCO2, ECO2 Optioneel bloedgassen en lactaat Systemen Hart Long Vaten Spieren Aansturing/neurologisch Bloed metabolisme

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11 Max VO2 VO2/wattage (% van voorspeld)

12 Hartfrequentie zuurstof pulse Hartfrequent/tijd (chronotrope incompetentie) Zuurstof puls = Cardiac output

13 Cardiac output = hf x slagvolume VO2 transport= cardiac output x a-vo2diff VO2 transport= hf x SV x a-vo2diff VO2 / hf= SV x a-vo2diff

14 In- expiratie tijd Ti, Te (in en expiratie tijd) Bij COPD/emfyseem Te >> Ti (normaal bij maximaal Te = Ti)

15 Gas transport eind insp mmhg kpa pa CO petco2 4,32 4,32 peco2 2,56 2,56 p(aco2-etco2) 35,68 5,1 mmhg > 2 mm hg is afw emfyseem of VQ p(et-eco2) 1,76 13,2 mmhg >13 is afw emfyseem

16 Ventilatoire efficientie VE/CO2 Gestoord bij circulatoire problemen (longembolien, hartfalen)

17 saturatie beloop Diffusie stoornis (geleidelijke daling) V/Q mismatch Shunt (plotse knik) Top athleet

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19 Eerst cardiale assesment

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21 Berekening van postoperatieve overgebleven long functionaliteit 5 de klas basis onderwijs Bepaling middels: CT scan V/Q scan / SPECT MRI

22 Maar ook: Gezond verstand 3 stairs = lobectomie 5 stairs = pneumectomie Wat wil de patient? High risq team overleg

23 Kun je op 1 kwab verder? 1. J Invest Surg May-Jun;8(3): A model of unilateral pulmonary lobar transplantation. Everett JE(1), Shumway SJ, Kroshus TJ, Bolman RM 3rd. Author information: (1)Department of Surgery, University of Minnesota, Minneapolis, USA. Unilateral lung transplantation has become an accepted treatment for patients with end-stage pulmonary disease. Donor shortage, however, is a major limitation, with up to 87% of patients dying of their pulmonary disease while awaiting transplantation. This is especially true in neonatal and pediatric patient populations. The use of organ segments from cadaveric or living donors may provide a solution. The purpose of this study, therefore, was to evaluate the function and hemodynamic response to pulmonary lobar transplantation using a swine model. Five transplants were performed for acute study, while 10 were performed for 6-week survival. The left lower lobe was harvested from a 70- to 75-kg donor animal. The lobe was then transplanted into a 20 to 25-kg recipient following left pneumonectomy. Graft function was determined by pulmonary arterial and venous blood gas analysis. Cardiac output, pulmonary pressure, and pulmonary vascular resistance were measured under two experimental conditions: (1) baseline and (2) with the right pulmonary artery occluded, forcing the entire cardiac output through the lobar graft. All grafts showed excellent acute and long-term function with regard to gas exchange. The lobar grafts, however, were characterized by high pulmonary vascular resistance both acutely and 6 weeks post-transplant. Contralateral pulmonary artery occlusion resulted in hemodynamic instability and right heart failure. No animal was able to be solely supported by the lobar transplant for more than one hour. These results have prompted a bilateral lobar transplant model and current studies are in progress.

24 Nationaal nascholingscongres anesthesiologie Conclusie Ergometrie is een onderzoek dat meer zegt dan VO2 max alleen Berekening post resectie functie volgens richtlijn ERS/ESTS 1 kwab gaat niet