#1
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Îáñëåäîâàíèå è íàáëþäåíèå ïîñëå áàðèàòðè÷åñêèõ îïåðàöèé
Âîïðîñ ê óâàæàåìîìó Âàäèìó Âàëåðüåâè÷ó:
Ãîä íàçàä ïàöèåíòêå 33 ëåò ñäåëàíà ðóêàâíàÿ ãàñòðîïëàñòèêà (sleeve gastrectomy). Ïîõóäåëà íà 50 êã, õîðîøåå ñàìî÷óâñòâèå, âíåøíå âûãëÿäèò êàê ôîòîìîäåëü. Ïðîøëà ïëàíîâîå îáñëåäîâàíèå. Ïðè ýòîì âûÿâèëèñü ñëåäóþùèå ïàðàìåòðû (â ñêîáêàõ íîðìà äàííîé ëàáîðàòîðèè): Ãåìîãëîáèí 120 ã/ë (120-140) Ýðèòðîöèòû 4.1 (3.9-4.7) Öâåòîâîé ïîêàçàòåëü 0.88 (0.85-1.05) Æåëåçî 6.4 ìêìîëü/ë (10.7-32.2) %íàñûùåíèÿ òðàíñôåððèíà æåëåçîì 10.24% (15-40%) ÎÆÑÑ 53.35 (44.8-80) òðàíñôåððèí 2.5 ã/ë (2-3.6) ôåððèòèí 5.9 ìêã/ë (10-120) âèòàìèí Â12 â íîðìå (íå ïîìíþ òî÷íóþ öèôðó, íî ïðèìåðíî â ñåðåäèíå ðåôåðåíòíûõ çíà÷åíèé). Âñå îñòàëüíûå ëàáîðàòîðíûå ïîêàçàòåëè â íîðìå. Ïðèíèìàëà ôåððóì-ëåê ïî 1 òàáëåòêå 3 ðàçà â äåíü íà ïðîòÿæåíèè 1.5 ìåñÿöà, ïàðàìåòðû æåëåçà íå èçìåíèëèñü. Âîïðîñ òàêîé: ÷òî ëó÷øå ïðèíèìàòü äàííîé ïàöèåíòêå, â êàêîé äîçå è äëèòåëüíîñòü êóðñà òåðàïèè. Áåñïîêîèò åå òîëüêî ñàì ôàêò íèçêîãî æåëåçà â àíàëèçàõ, áåç êëèíè÷åñêèõ ïðîÿâëåíèé. |
#2
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Ó ïàöèåíòêè èìååòñÿ è ïîãðàíè÷íûé ãåìîãëîáèí - ïðåäàíåìèÿ (íîðìà åãî ó æåíøèí 122-153). Ôåððóì-ëåê ñêîðåå âñåãî íå óñâàèâàåòñÿ, íóæíû ïðåïàðàòû æåëåçà-2 (ôåððåòàá, òàðäèôåðîí è òï.). Åñëè è íà ôîíå èõ ïðèåìà æåëåçî â ñûâîðîòêå íå ïîäðàñòåò è ãåìîãëîáèí ÷åðåç 3-4 íåäåëè íå ñòàíåò áîëåå 125, òî â/â ââåäåíèå (âåíîôåð, ôåðèíäæåêò), è ýòî ïîæèçíåííî èëè äî ìåíîïàóçû
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#3
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Öèòàòà:
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#4
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Óâàæàåìûé Âàäèì Âàëåðüåâè÷,
Ïðîñüáà ïðîêîììåíòèðîâàòü ñëåäóþùèå ðåçóëüòàòû òåñòîâ: Hb 126 ã/ë æåëåçî 16 (9-30) ôåððèòèí 7 (10-120) Ó ïàöèåíòêè ïîëãîäà ïîñëå îïåðàöèè ãàñòðîïëèêàöèè (íè÷åãî íå îòðåçàåòñÿ, îáúåì æåëóäêà óìåíüøàåòñÿ øâàìè), ïîòåðÿ 30 êã. Ïàöèåíòêà íè íà ÷òî íå æàëóåòñÿ, ïëàíîâîå îáñëåäîâàíèå, äðóãèõ îòêëîíåíèé (êðîìå ñíèæåíèÿ ôåððèòèíà) â àíàëèçàõ íåò. Ïàöèåíòêà âîëíóåòñÿ òîëüêî íà ñ÷åò ñàìîãî ôàêòà ñíèæåíèÿ ôåððèòèíà. |
#5
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À êàêèå öèôðû ôåððèòèíà áûëè äî ýòîãî? Ãåìîãëîáèí çà ïîñëåäíåå âðåìÿ íå ñíèæàëñÿ? äð. ïîêàçàòåëè îá. àíàëèçà êðîâè åñòü - ýðèòðîèíäåêñû?
Öèôðû ôåððèòèíà óêàçûâàþò íà ïîëíîå îòñóòñòâèå çàïàñîâ æåëåçà â îðãàíèçìå (ôåððèòèí ìåíåå 12), åñëè îòðèö. æåëåçíûé áàëàíñ ñîõðàíèòñÿ (äåôèöèò æåëåçà â åäå, îáèëüíûå ïîòåðè ñ ìåíñòð. êðîâüþ), òî ãåìîãëîáèí ïðîäîëæèò ñíèæåíèå. Ïðîôèëàêòè÷åñêè - óñèëèòü ðàöèîí ìÿñíîé åäîé, äîáàâèòü ïð-ò æåëåçà õîòÿ áû 0.6-0.8 ìã/êã âåñà
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#6
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Öèòàòà:
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#7
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Íåò íóæäû äåëàòü ýòè èññëåäîâàíèÿ ïåðåä îïåðàöèåé, èõ è äð. ïðîâîäÿò â ïîñëåîïåðàöèîííûé ïåðèîä, íà÷èíàÿ ñ 3 ìåñÿöåâ, ïîòîì â 6 ìåñ. è çàòåì åæåãîäíî, ñîãëàñíî ðåêîìåíäàöèÿì:
The following laboratory tests are performed at three months, six months, and annually thereafter, in general agreement with published guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient: ●Complete blood count ●Electrolytes ●Glucose ●Iron studies, ferritin ●Vitamin B12 ●Aminotransferases, alkaline phosphatase, bilirubin ●Albumin ●Lipid profile ●25-hydroxyvitamin D, parathyroid hormone (PTH) ●Thiamine ●Folate ●Zinc ●Copper Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic&Bariatric Surgery. Obesity (Silver Spring). 2013 Mar;21 Suppl 1:S1-27.
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
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#8
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Íàøè ðåêîìåíäàöèè â öåëîì òàêèå æå. Òåì íå ìåíåå óðîâåíü äèñöèïëèíû ñäà÷è ïîñëåîïåðàöèîííûõ àíàëèçîâ î÷åíü íèçêèé. Ìíîãèå ëþäè íè÷åãî íå êîíòðîëèðóþò ãîäàìè.
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#9
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ÆÄÀ ïîñëå áàðèàòðè÷åñêèõ âìåøàòåëüñòâ - ñëåäñòâèå èëè èíäèêàòîð ïîâûøåííîé ÷àñòîòû ïîñëåîïåðàöèîííûõ îñëîæíåíèé? àíàëèç èç ÑØÀ:
J Manag Care Spec Pharm. 2015 Oct;21(10):946-954. Burden of Iron Deficiency Anemia in a Bariatric Surgery Population in the United States. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#10
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Âîïðîñ ä-ðó Vad:
Ïàöèåíòêà 4 ãîäà ïîñëå îïåðàöèè Sleeve. Áûëî íèçêîå æåëåçî. Ïèñüìî îò ïàöèåíòêè: Öèòàòà:
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#11
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ïîêà áû îñòàâèë ñîðáèôåð â òàêîé äîçå ìèíèìóì íà 1.5-2 ìåñ., çàòåì ïîâòîð ÎÀÊ è ïî åãî ðåçóëüòàòàì êîððåêòîðîâàòü äîçó
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#12
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#13
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Öèòàòà:
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#14
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åñëè íåò äåôèöèòà öèíêà èëè Â12 èëè èíôåêöèè íàêàíóíå, êîãäà áûâàåò ëîæíî ïîâûøåí ôåððèòèí , ïðîñòî ïåðåñòàòü ïðèíèìàòü è âñå, ôîðìà ôåððèòèíà ó ìóæ÷èí äî 300, ïðè íåàëêîãîëüíîì ñòåàòîçå áûâàþò öèôðû è áîëåå 450
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#15
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