#1
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Ïîâåñåëèì íàðîä!
Ñîâñåì â ýòîì ðàçäåëå ñòàëî òîñêëèâî!Ïðåäñòàâëþ Âàøåìó âíèìàíèþ îäíó íàøó ïàöèåíòêó.
Àôðî-àìåðèêàíêà 54 ëåò ðîñò 160 âåñ 204 (äâåñòè ÷åòûðå) êã ñ ãèïåðòîíèåé, sleep apnea, ãèïåðíåôðîìîé,ïðîðàñòàþùåé â íèæíþþ ïîëóþ âåíó íàçíà÷åíà íà ïðàâîñòîðîííþ ðàäèêàëüíóþ íåôðýêòîìèþ è ðåçåêöèåé îïóõîëè íèæíåé ïîëîé âåíû. Áîëüíàÿ ïðèíèìàåò Ëèçèíîïðèë,Àòåíîëîë, Àñïèðèí (îñòàíîâëåí 5 äíåé íàçàä), ðåêîìáèíàíòíûé Ýðèòðîïîýòèí,Æåëåçî, Ôîëèåâóþ êèñëîòó,âèòàìèí Ñ. Ãåìîãëîáèí 96, ãåìàòîêðèò 27.7.Ðåòèêóëîöèòû 5.4%. Áîëüíàÿ - ñâèäåòåëüíèöà Èåãîâû, îò ïåðåëèâàíèÿ ïðåïàðàòîâ êðîâè îòêàçûâàåòñÿ.Êîíñåíò ïîäïèñàí.  õèðóðãè÷åñêîì àíàìíåçå - óäàëåíèå ëåéîìèîñàðêîìû ìàòêè íåñêîëüêî ìåñÿöåâ íàçàä ( ñ ìîèì ó÷àñòèåì). ×òî áóäåì äåëàòü?? |
#2
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À íåëüçÿ ïîíåìíîæêó àóòîêðîâè çàãîòîâèòü? Íó õîòü ÷óòü-÷óòü äëÿ ñòðàõîâêè??? Õîòÿ, ñóäÿ ïî àìåðèêàíñêèì ñîîáùåíèÿì ïðî ýòèõ ñàìûõ ñâèäåòåëåé Èåãîâû - äàæå ïðè êðîâîïîòåðå áîëåå 2,5 ëèòðîâ è ãåìîãëîáèíå ìåíåå 5,0 ñïðàâëÿþòñÿ òîëüêî ïëàçìîçàìåùàþùèìè ðàñòâîðàìè.
Sorry (c) åñëè ÷òî.... |
#3
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Öèòàòà:
Ó íàñ åñòü âðà÷, êîòîðàÿ ñîñòîèò â ýòîé ñåêòå. Íà êàêóþ-òî êðóïíóþ îïåðàöèþ (íå ïîìíþ, êàêóþ) åé ñåêòàíòû ñêèäûâàëèñü íà ïëàçìîçàìåíèòåëè è "ãîëóáóþ êðîâü"- ïåðôòîðàí. |
#4
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Öèòàòà:
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#5
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Íàñêîëüêî ÿ íàñëûøàí, ïðîáëåìà â òîì, ÷òî êðîâü ïîêèíóëà òåëî è âîçâðàòó íå äîëæíà ïîäëåæàòü. ×òî - òî òàê ó èåãîâèñòîâ, IMHO. Àëüòåðíàòèâà ñ ìåøêîì, êîòîðûé íàïîëíÿåòñÿ àóòîêðîâüþ è íàõîäèòñÿ ðÿäîì ñ áîëüíûì, ìîæåò íå ïðîéòè. Êðîâü òåëî ïîêèíóëà.
 Ðîññèè ïîäîáíóþ äàìó ìîãëè íå òîëüêî ïðîîïåðèðîâàòü, íî è êðîâè ïîä øóìîê ïîêàïàòü, ïðÿìî â îïåðàöèîííîé. È â ïðîòîêîëå ñåé ôàêò óêàçàòü ÷åðåç ìåñÿöà äâà-òðè, êîãäà âñå óñòàêàíèöà. Âàøà äàìà, íàçíà÷åííàÿ íà îïåðàöèþ, áóäåò ïîëó÷àòü ïëàçìîçàìåíèòåëè. Õîðîøî ïîâåíòèëèðóåòñÿ. È ãåìîãëîáèí áóäåò íàãîíÿòü ñàìà. |
#6
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Îêîëî ìåñÿöà íàçàä â íåéðîõèðóðãè÷åñêîì îòäåëåíèè ïðîõîäèëà ïîäîáíàÿ áîëüíàÿ èç ñåêòû. Âðà÷, áûâøèé àíåñòåçèîëîã, êñòàòè.. Òîæ ïåðôòîðàí çàêàçûâàëè. Îò ýêñôóçèè êàòåãîðè÷åñêè îòêàçàëàñü.
À íåêîòîðûõ èåãîâèñòîâ óäàåòñÿ óãîâîðèòü äàæå íà äîíîðñêóþ îò ðîäñòâåííèêîâ. |
#7
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Öèòàòà:
Ýòî æå ñêîëüêî åé ïåðôòîðàíà íà îïåðàöèþ íàäî? È âîîáùå ó Âàñ åãî èñïîëüçóþò? Ìîæåò ïîõîäó îïåðàöèè èñïîëüçîâàòü âûñîêîé êîíöåíòðàöèè êîëëîèäû! |
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#8
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Ðèñêóþ íà íåîäîáðåíèå...íî ïîïðîáóþ...
204 êã ÿ ñåáå, åñëè ÷åñòíî íå ïðåäñòàâëÿþ êàê âûãëÿäÿò...ÈÌÕÎ Hb 96 íå òàê ñòðàøåí. Ñ ÝÊÊ íèêîãäà íå ðàáîòàë, íî, äóìàþ, åñëè îïóõîëü âðàñòàåò â ñòåíêó,òî ïðèäåòñÿ èñïîëüçîâàòü. Äóìàþ, Ht 27 òîæå íå ïîìåõà - äîïóñòèìà ãåìîäèëþöèÿ äî 15. Åñëè ÝÊÊ íå èñïîëüçîâàòü (òðîìá âíóòðèïðîñâåòíûé), òî â íàøèõ óñëîâèÿõ - âñêðûòèå ïðîñâåòà (ïîñëå ïåðåæàòèÿ ñîñóäà), ââåäåíèå êàòåòðà Ôîãàðòè , ýêñòðàêöèÿ òðîìáà, óøèâàíèå ñòåíêè. Îñíîâíûå ïðîáëåìû äëÿ àíåñòåçèîëîãà, òðèæäû ÈÌÕÎ - íå äîïóñòèòü ðàçâèòèÿ îñòðîé ñåðäå÷íî-ñîñóäèñòîé íåäîñòàòî÷íîñòè íà ôîíå àíåìèè, íàâåðíÿêà ñíèæåííîãî Ñ (êîíòðîëü äî îïåðàöèè, åñëè ñíèæåí, òî êàòåòð â ëåã. âåíó, èíâàçèâíûé ìîíèòîðèíã ÀÄ, ïîä ðóêîé - äîáóòàìèí äëÿ óëó÷øåíèÿ äîñòàâêè êðîâè ê òêàíÿì). Èíòóáàöèÿ â ñîçíàíèè (èáî 204 êã 8( ), ëèáî ïîñëå èíäóêöèè - ËÌÀ èëè òðóáó (áðîíõîñêîï ïîä ðóêîé, êàê âàðèàíò - íà ñïîíòàííîì äûõàíèè. Ââîäíûé: ìèäàçîëàì, êåòàìèí èëè ìèäàçîëàì, ïðîïîôîë (åñëè Ñ íå ñèëüíî ñíèæåí), àíàëãåçèÿ ôåíòàíèëîì. Íà ïîääåðæàíèå ìîæíî N2O, íî ìîæåò ñíèçèòü ÑÂ. Êñòàòè, ìîæíî ïðîâåñòè óïðàâëÿåìóþ ãèïîòîíèþ (íèòðîãëèöåðèí èëè ...) íà ôîíå ãèïåðäèíàìè÷åñêîé ãåìîäèëþöèè (îïÿòü æå ñíèçèì ïîòåðþ Hb âî âðåìÿ îïåðàöèè). ÇÛ- Ïàïàäîê, çàðàíåå ñïàñèáî çà êðèòèêó, íàâåðíÿêà ÷òî-íèáóäü óïóñòèë, ò.ê . òÀêèõ áîëüøèõ ïàöèåíòîê íå âèäåë è ñ ÝÊÊ íå ðàáîòàë. |
#9
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Ïî ïîâîäó ïåðôòîðàíà. Íå î÷åíü â íåãî âåðþ, íî.. Íå òàê äàâíî èç îáëàñòè ïðèâåçëè äåäóøêó, êîòîðûé ñ ïîëãîäà íàçàä îòêàçàëñÿ îò îïåðàöèè. Îï. æåëóäêà ñ ðàñïàäîì. Êðîâèë, âèäèìî äàâíî ( Hb íè òî 37 íè òî27), íî êîìïåñèðîâàí, ò.ê. ñ òàêèìè ïîêàçàòåëÿìè ïðèøåë ïåøêîì. Èåãîâà. Ðîäñòðåííèêè ïðèïåðëè ÿùèê ïåðôòîðàíà (îêîëî 60-70$ çà 100 ìë).  ñðî÷íîì ïîðÿäêå ïàëëèàòèâíàÿ ðåçåêöèÿ æåëóäêà. Âûïèñàí íà ñâîèõ íîãàõ. Ýðèòðîïîýòèí, êîíå÷íî, øåë, íî óæå ïîñëå îïåðàöèè, åñòåñòâåííî.  ðåìàíàöèè ïåðåëèëè 2 èëè 3 ôëàêîíà ïåðôòîðàíà, îñòàëüíîå â ïðîôèëüíîì îòäåëåíèè. Îí ëè ïîìîã...èëè ïðîñòî äåäóøêà "ïðèâûê" æèòü íà òàêîì Hb??!
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#10
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Ýðèòðîïîýòèí, êîíå÷íî, øåë, íî óæå ïîñëå îïåðàöèè, åñòåñòâåííî.
Èçâèíèòå , à ñêîëüêî ýðèòðîïîýòèí â Ðîññèè ñòîèò ? |
#11
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Öèòàòà:
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#12
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Öèòàòà:
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#13
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Ñïàñèáî âñåì çà ïðåäîñòàâëåííóþ èíôîðìàöèþ !
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#14
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Öèòàòà:
2. Êàê ÿ ïîíèìàþ óñòðîéñòâî äëÿ ïðîöåññèíãà êðîâè òåðÿåìîé èç ðàíû- ñåëë-ñåéâåð - èñïîëüçîâàíî áûòü íå ìîæåò. 3. Âî ñêîëüêî îáîéäåòñÿ ýòîé ïàöèåíòêå òàêàÿ îïåðàöèÿ è âî ñêîëüêî áû îíà îáîøëàñü, åñëè áû áûëî âîçìîæíî èñïîëüçîâàòü ñåëë-ñåéâåð, çàãîòîâêó àóòîêðîâè èíòðàîïåðàöèîííî. 4. Íå ñîáèðàþòñÿ ëè åå ïðîñòî ïîäêëþ÷èòü ê ïîðò-àêñåññ áàéïàñó è ñïîêîéíî ñîáèðàòü òåðÿåìóþ êðîâü îòñîñàìè â êîíòóð, ïîêà îáùèå õèðóðãè çàíèìàþòñÿ ïî÷êîé è ÍÏÂ, èìåÿ ïðè ýòîì âîçìîæíîñòü äåëàòü è èíòðàîïåðàöèîíóþ ãåìîäèëþöèþ è ïîñëåäóþùóþ óëüòðàôèëüòðàöèþ äëÿ ãåìîêîíöåíòðàöèè? Âîîáùå ïàöèåíòêà ïðîèçâîäèò âïå÷àòëåíèå ýêñòðåìàëüíîãî ñèìóëÿòîðà àíåñòåçèè. êîãî-òî ìíå íàïîìèíàåò ýòîò ñòèëü. |
#15
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Åñëè ïðåäïîëîæèòü, ÷òî áîëüíàÿ ïîëó÷àåò ïîëíóþ äîçó ýðèòðîïîýòèíà è æåëåçî ó íåå âñàñûâàåòñÿ õîðîøî (åñëè âíóòðü) èëè äîñòàòî÷íàÿ äîçà (èíòåðåñíî êàêîå æåëåçî ïîëó÷àåò, ïóòü ââåäåíèÿ?), òî åñòü íåáîëüøèå íàáëþäåíèÿ, ÷òî îòíîñèòåëüíóþ óñòîé÷èâîñòü ê ýðèòðîïîýòèíó ìîæíî ïðåîäîëåòü, íàçíà÷èâ àíòèöèòîêèíîâóþ òåðàïèþ ïåíòîêñèôèëëèíîì, è àíåìèÿ ìîæåò êîððåêòíóòüñÿ:
J Am Soc Nephrol. 2004 Jul;15(7):1877-82. Pentoxifylline improves hemoglobin levels in patients with erythropoietin-resistant anemia in renal failure.Cooper A, Mikhail A, Lethbridge MW, Kemeny DM, Macdougall IC. Department of Renal Medicine, GKT School of Medicine, King's College Hospital, London, United Kingdom. It was hypothesized that pentoxifylline might improve the response to recombinant human erythropoietin (rh-Epo) in anemic renal failure patients. Sixteen patients with ESRD and rh-Epo-resistant anemia, defined by a hemoglobin of <10.7 g/dl for 6 mo before treatment and a rh-Epo dose of > or =12,000 IU/wk, were recruited. They were treated with oral pentoxifylline 400 mg o.d. for 4 mo. Ex vivo T cell generation of tumor necrosis factor alpha (TNF-alpha) and interferon gamma (IFN-gamma) from the patients was assessed before treatment and 6 to 8 wk after therapy. A total of 12 of 16 patients completed the study. Before therapy, the 12 patients' mean hemoglobin concentration was 9.5 +/- 0.9 g/dl. After 4 mo of pentoxifylline treatment, the mean hemoglobin concentration increased to 11.7 +/- 1.0 g/dl (P = 0.0001). Baseline ex vivo T cell expression of TNF-alpha decreased from 58% +/- 11% to 31% +/- 23% (P = 0.0007) after therapy. Likewise, IFN-gamma expression decreased from 31% +/- 10% to 13% +/- 10% (P = 0.0002). Pentoxifylline therapy may significantly improve the hemoglobin response in patients with previously rh-Epo-resistant anemia in renal failure. This may occur due to inhibition of proinflammatory cytokine production, which could interfere with the effectiveness of rh-Epo. Ñ ïîëíûì òåêñòîì íåäàâíåãî îáçîðà îäíîãî èç àâòîðîâ ìîæíî îçíàêîìèòüñÿ çäåñü: Nephrol Dial Transplant. 2004 Aug;19 Suppl 5:V73-78. Could anti-inflammatory cytokine therapy improve poor treatment outcomes in dialysis patients? [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Ïîíÿòíî, ÷òî ïàöèåíêòà íå ñ òåðì. ÕÏÍ, íî öèòîêèíåìèÿ ìîæåò áûòü è íå òîëüêî ïðè äàííîì ñîñòîÿíèè.
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |