tehnica drenajului percutan in ascita refractara din ciroya hepatica

1. Drenajul peritoneal continuu in
ascita refractara
Alexandru Andritoiu, MD
Dept. Medicina Interna
www.smucraiova.ro

5. De evitat arterele epigastriceDe evitat arterele epigastrice
inferioareinferioare!!

6. ParacenteParacentezaza
• Repeated large-volume paracentesis (4-6 L/day)
• Total paracentesis (single-day hospitalization
regime)
Postparacentesis circulatory dysfunction is not spontaneously reversible
and is associated with a shorter time to first readmission and shorter
survival.
Postparacentesis circulatory dysfunction was defined as an increase in
plasma renin activity on the sixth day after paracentesis of more than
50% of the pretreatment value to a level > 4 ng.mL-1.h-1.
Albumin is the best plasma expander to prevent this complication
Plasma expanders: Haemaccell, Dextran 70

10. CCateterateterele tunelateele tunelate

11. CateterCateter TenckhoffTenckhoff

12. Kit de drenajKit de drenaj PleurXPleurX
Placement of a permanent, tunnelled peritoneal drainage catheter (PleurX) for refractory malignant and portal-
hypertensive ascites in a multicentre study
G.-M. Semadeni GM et al, J Hepatology 2015 62 S381

13. Kit de drenajKit de drenaj AspiraAspira

14. Kit de drenaj ASEPT
Sistemul de drenaj ASEPT:
cateter drenaj ASEPT™
seringa 10cc
ac de insertie cu fir de ghidare 18G
fir de ghidare in forma de J
introducator de extragere
tunelar
adaptor linie drenaj 5 in 1
linie drenaj ASEPT™ cu capac
suport cateter din spuma
tampoane tifon 4”x4” (10 cm x 10 cm)
280 RON
1.190 RON

15. Cateter Pigtail

17. • Pac. 69 ani
• ICC cls IV-CMD
• Ascita cardiaca
• Cateter peritoneal
permanent (PleurX)
• Drenaj la domiciliu 2-4 L
ascita/sapt.

18. Durata drenajuluiDurata drenajului
• 500-1000 mL/h
• 3-4 h/zi

19. No drainageNo drainage:
La ce te poti astepta…
Blocaj – spala cateterul cu jet de solutie
salina sterila
Kinking-ul tubului de dren
Drenul a iesit din cavitatea
peritoneala – inlocuiste-l cu altul nou
intr-un alt loc

20. Caz clinic 1Caz clinic 1
• MM.. MMarianarian,, 47 ani
• Diagnostic:Diagnostic:
• Ciroza hepatica etanolica
• Ascita voluminoasa (grad 3)
• Drenaj continuu peritoneal (Seldinger)
cateter venos central

21. Analize laboratorAnalize laborator
TQ 19s
AP 45%
INR 1.39
Tb 86.000 mmc

22. US AbdominalaUS Abdominala

23. Ghidaj ecograficGhidaj ecografic
Anestezie locala 10 mL Xilina 1%

24. Insertia firului ghidInsertia firului ghid

25. Insertie dilatatator pe firul ghidInsertie dilatatator pe firul ghid

26. Insertie cateter pe firul ghidInsertie cateter pe firul ghid

27. Control USControl US
Imediat/post-procedura Ziua a 3-a

28. CT AbdomenCT Abdomen
F
A
A-ascita, F-ficat
Sageta-dren intraperitoneal

29. TratamentTratament
• Diuretic (Spiroloactona 50 mg/z+Furosemid 40
mg/z)
• Albumina (i.v.)
• Hepatoprotectie (Aspatofor, Arginina)
• AB (Sulcef 2g/z i.v.+ Ciprofloxacin 500mg x2/z)
• Drenaj continuu 7 zile (11.000 mL)

30. Curba greutatiiCurba greutatii
65
70
75
80
85
90
95
z 1 z 2 z 3 z 4 z 5 z 6 z 7 z 8 z 9 z 10 z 11 z 12 z 13
G (kg)
Drenaj continuu 7 zile

31. Caz clinic 2Caz clinic 2
P. Florea, 58 ani
• Diagnostic:Diagnostic:
• Ciroza hepatica vir. B+Alcool
• Ascita refractara
• Scor MELT: 19

32. Istoric
• 2012-colectectomie icter mecanic litiazic
• Ciroza hepatica VHB
• Biopsie hepatica intra-oper (Sp. CFR-Cva)
• 1 luna post-oper-decomp. ascitica
• Repetate spitalizari (ascita recurenta)
• Ian-Febr. 2014: Spit. Calafat (ascita
refractara: Spirono 6 cp, Furosemid 2 cp/z)-
fara rezultat!

33. Ex. clinicEx. clinic
• Abdomen destins, in tensiune
• Ascita abundenta
• Circulatie colaterala P/C

34. Ex. biologiceEx. biologice
• Tb 167.000/mmc
• TQ 22 s;
• AP 36%;
• INR 1.6

35. Cateter drenaj ascita (z 3)Cateter drenaj ascita (z 3)

36. Monitorizare functii vitaleMonitorizare functii vitale
Diureza < 1000 mL/zi

37. Drenaj 3500 mLDrenaj 3500 mL
Cefort 1g in PEV–Glucoza 5% 500 mL
PEV Dextran 70-glucoza 500 mL

38. Curba greutatii (Kg)Curba greutatii (Kg)
83 83 83
78
80 80
77.5
76
75 74.5
73 73 73 73 72.5
70
60
65
70
75
80
85
z 1 z 2 z 3 z 4 z 5 z 6 z 7 z 8 z 9 z 10 z 11 z 12 z 13 z 14 z 15 z 16
G (Kg)
Cateter peritoneal
Drenaj 1000 3500 3500 3500 4000 1800 1100 1700 1500 1500 2000 1500 1000 1500
Na 125 mmol/L Na 110 mmol/L
K 5.24 mmol/LK 5.98 mmol/L
Uree 53 mg/dL
Creatinina 0.9 mg/dL
Uree 90 mg/dL
Creatinina 1.46 mg/dL
Uree 85 mg/dL
Creatinina 1.2 mg/dL

39. TratamentTratament
• Albumina
• Aspatofort iv, Arginina, Liv 52, Silimarina
• Furosemid (1/2 f im), Spironolactona 25 mg x2
• Ampicilina 2 x 1 g – PEV, Ciprofloxacina 500
mg x 2, Normix 2 x 2 cp/z
• Sol. Dextran 70 (glucoza), Sol. Ringer,
• Pantoprazol 2x20 mg/z
• Fitomenadion 2x 1f i.m.
• Aspavim

40. Case clinic 3
P. Gheorghe, 54 ani
• Ciroza hepatica vir B –Ascita refractara
• Icter
• Tum hep. centrohilara (Colangiocarcinom)
• VSH 52 mm/h
• Tb 74.000/mmc
• INR 1.34
• BRT 7.5 mg/dL
• CA 19-9 58u/mL (N<35)

41. US-Abdomen
Ficat cirotic
Ascita
Tumora centro-hilara
Dilatatii CBIH

42. RMN Abdomen
• macronodul tumoral centro-hilar si in segm.
IV-VIII, in hipersemnal T2, hiposemnal T1,
heterogen postcontrast de 6/5 cm - ce
determina obstructia cailor biliare
intrahepatice

43. Drenaj ascita

44. Colangiografie percutana

45. Drenaj bilar extern-percutan
Z-4: angiocolita, sepsis, MSOF, exitus (Acynetobacter)

46. ComplicatiiComplicatii

48. ConcluziiConcluzii
• Drenajul percutan continuu al ascitei
refractare in CH poate fi o solutie
terapeutica (…costisitoare!)
• Atentie la:
• aspectul ascitei in zilele urmatoare
• riscul de infectie, in ciuda protectiei cu AB
• monitorizarea ionogramei serice si TA