Drenajul pericardic percutan in pericardita neoplazica
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rolul ultrasonografiei in ghidajul pericadocentezei si drenajului pericardic percutan la pacientii cu pericardita neoplazica
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Drenajul pericardic percutan in pericardita neoplazica
- 1. DRENAJUL PERICARDIC PERCUTAN GHIDAT ECOGRAFIC IN PERICARDITA CRONICA NEOPLAZICA Alexandru Andritoiu, Aurelia Resceanu, Cristian Silosi, Andritoiu Paul Demetrian, Corina Drighiciu, Florin Robescu Sp. Militar Craiova
- 2. Indicatii • Pericardita cronica • Tamponada subacuta
- 3. Scop • Diagnostic • Terapeutic - hemodinamic • Drenaj evacuator
- 4. Tehnica • Trusa drenaj • Ecograf • Monitorizare ATI : TA, AV, ECG, SaO2
- 5. 1. Caz clinic • F Ghe, F, 68 yr • Edeme mm infer-perete abd infiltrat • Dispnee, ortopnee, • Tuse seaca, iritativa • Scadere G • Afebrila • Biol: VSH 34/47 mm • Fibrinogen 944 mg/dl
- 6. US • Doppler venos mm infer: exlude tromboza vv prof. • Eco cord: revarsat pericardic progresiv • Eco abd: ficat de staza; revarsat pleural bilater; exclude tromboza VCI
- 12. Ex laborator – lichid pericardic • • • • • R. Rivalta (++) Proteine 5.4 g/ml CEA –slab pozitiv !? Culturi negative (aerobe); Frotiu: inflamator; fara atipii celulare!
- 13. Drenaj pericardic continuu percutan sub ghidaj US
- 17. Control US
- 18. Fi.A paroxistica
- 20. Rx (control 48 ore)
- 21. CT
- 23. 2. Caz clinic • CS, F, 80 ani • Pericardita cronica • Insuf. Card cls 2/3
- 24. Rx C- P
- 25. CT
- 26. ECG RS, T neg. D1, D2, aVL, V4-V6
- 27. Ecocardiografie
- 29. Zoom
- 30. CT
- 31. Examene biologice • VSH: 41-99 mm/h • Proteina C reactiva - pozitiva
- 32. Diagnostic de etapa • Pericardita cronica-hemoragica • Mezoteliom pericardic ?
- 33. Drenaj pericardic 14 zile
- 34. Adm. Intra-pericardica • Cisplatinum 10mg x 5 z • Gentamicina 80 mg
- 35. Suport ATI
- 38. Insertie cateter
- 40. Monitorizare ECG, TA, SaO2
- 41. Control Rx
- 45. Lichid pericardic – z 12
- 46. Benzi de fibrina flotante
- 47. Benzi de fibrina
- 48. Examen lichid pericardic BIOCHIMIE Proteine: 5.1 g/dL LDH 903 UI/L CRP 0.2 mg/dL Glucoza 82 mg/Dl CEA negativ CITOLOGIE Frotiu hipercelular, hemoragic, Frecvente celule mezoteliale dispuse izolat sau in grupuri, unele de dimensiuni mari, cu citoplasma bazofila, cu unul sau mai multi nuclei , cu nucleoli vizibili, uneori multipli; Relativ frecvente limfocite; Rare PMN. CULTURA - NEGATIVA
- 49. Cispatinum 5 x 10 mg/zi - intrapericardic
- 50. Caz clinic 3 • ILIE CONSTANTIN, 53 ani, Craiova
- 51. Motivele internarii • Durere intensa-prelungita cervico-brahial stg (de peste 2 luni)-AINS, antialgice • Sincope repetate-hipoTA • Stare generala alterata • Voce ragusita • Fumator >35 ani-40 tigarete/zi • AHC-tatal decedat Neo Br Pulm (mare fumator)
- 52. Ex. obiectiv • Facies suferind • Formatiune dura-dureroasa la insertia claviculara a muschiului SCM stg • Torace hipostenic-fara modificari stetacustice • Echilibrat C-V (TA 110/65 mmHg;AV 80 bpm)
- 54. US/10.10.2013 Cervicala • Bloc adenopatic stg Eco tiroida • Noduli benigni bilateral Eco-cord-relatii normale Eco Abdmen • Colecist exclus chirurgical • Ficat, pancreas, splina, RD, RS, vezica urinara, prostate-normale
- 55. Diagnostic de etapa In obs: Neoplasm bronho-pulmonar Elemente: • Fumator (+++) • Ereditate: tatal decedat de neo pulmonar • Voce ragusita • Adenopatie tumorala (maligna)
- 56. 14.10.2013/ CT toracic • Laringe asimetric-formatiune infiltrativa lateral stg+bloc adenopatic latero-cerv stg • Pulmon, mediastin, pleura-normale Dr. Demetrian Paul
- 57. 15.10.2013 Laringoscopie endoscopica • Paralizie de coarda vocala stg • Infirma neoplasmul laringian Dr Cheita Nicolae
- 58. Evolutie intraspitaliceasca • • • • • Dureri atroce cervical stg Scadere ponderala (facies malign) Tuse seaca Dispnee progresiva Ziua - prabusire TA (TAS 70-80 mmHg)
- 59. 27.10.2013/Eco cord • Pericardita (revarsat abundent > 3 cm anterior) • Semne de tamponada sub.acuta
- 61. Atitudine terapeutica • Punctie pericardica • Drenaj pericardic • Biopsie ganglionara (supra-clavicular stg) Anestezie generala Dr. Andritoiu A, Dr Silosi C, Dr. Resceanu Aurelia
- 63. Drenaj pericardic percutan (tehnica Seldinger) ghidaj ecografic
- 65. Ex. Citologic (lichid pericardic) • • • • • Frecvente hematii Frecvente mezotelii (mezoteliom pericardic?) Rare leucocite Aspect ,,reactiv,, Fara celule maligne! 30-50% din cazuri-citologie negativa!!! Dr. Drighiciu Corina
- 66. 30.10.2013/ Repeta CT toracic • • • • • Pericardita Pleurezie bilaterala Colabare lob inf stg Adenopatie Tum hilara
- 67. CT – cateter pericardic
- 68. Evolutie • • • • Aspirat continuu >100 ml/zi Refacere rapida Aspect hemoragic • • • • • • • Tratament AB HSHC Etamsilat Suport inotrop pozitiv Antialgice Oxigen TA 100/65 mmHg, AV 90 bpm, SaO2 85-92%
- 69. Chimioterapie locala • • • Cisplatin 3 zile Fara rezultat favorabil 10 mg+20 ml Na Cl (dilutie)/zi
- 70. Toracenteza • 01.11.2013 • Punctie pleurala stg Lichid sero-citrin • Drenaj pleural stg Evacuare > 1000 mL Dr. Dobrinescu Adrian, Cl Chir Toracica, Sp Jud nr 1 Craiova
- 71. • • • • • • • • • • • • VSH 30-36 mm/h Le 11.790/mmc Hb 15.6-11.4 g/dL Ht 43-31% Fibrinogen 457-471 mg/dL CRP 7.9 mg/dL TGO 14-91 UI/L TGP 14-375 UI/L Ac. bK negativi Mb negativ CPK-MB 23 UI/L LDH 432 UI/L
- 72. Biochimie (lichid pericardic) • • • • Proteine g/dL Glucoza 62 mg/dL LDH 2933 UI/L R. Rivalta Poz (+++)
- 75. Cisplatinium Efecte adverse • • • • • • • • Gastro-intestinale: greata, varsaturi Cardiovasculare: aritmii, HTA, cardiotoxicitate Renale: nefrotoxicitate SN: polineuropatie senzitiva periferica Hematologice: anemie, mielosupresie Oculare: nevrita optica, edem papilar, orbire Hepatice: TGO, BR> Dermatologice: rush, alopecie.
- 77. Intrapericardial Cisplatin treatment prevents effectively the recurrence of neoplastic pericardial effusion B. Maisch, S.Pankuweit, H. Rupp, A. Ristic, Conclusion: • Intrapericardial treatment with cisplatin prevents recurrences of NE effectively. The treatment was more successful in lung than in breast cancer pts. Circulation. 2009;120:S885