#1
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ñòåíòèðîâàíèå è ðàê æåëóäêà, òàêòèêà?
Âå÷åð äîáðûé. íà îáñóæäåíèè ïàöèåíò 65 ëåò, ñòàáèëüíàÿ ñòåíîêàðäèÿ ÔÊ3, áåç ÈÌ â àíàìíåçå. Îáñëåäîâàí ÊÀà 6 ìàÿ 2016ã: êðèò ñòåíîç ÏÌÆ 2-é ïîðöèè â îñòàëüíîì áåç îñîáåííîñòåé. ãîñïèòàëèçèðîâàí äëÿ îïåðàòèâíîãî ëå÷åíèÿ 19 èþíÿ â àíàëèçàõ êðîâè Íâ - 60, Ýð - 2.7. ïðè äîîáñëåäîâàíèè: ÔÃÄÑ - ðàê àíòðàëüíîãî îòäåëà æåëóäêà, ñ èçúÿçâëåíèåì ïîêðûòì ôèáðèíîì, öèîòîëîãèÿ è ãèñòîëîãè àäåíîêàðöèíîìà, ÊÒ - ïîäòâåðæäåíèå ïðîöåññà áåç ìåòàñòàçîâ. Ó÷èòûâàÿ ïàòîëîãèþ ïî êîðîíàðíûì àðòåðèÿ îíêîëîãè ïðîñÿò ïðîñòåíòèðîâàòü àðòåðèþ íà ôîíå ââåäåíèå Íà â òå÷åíèè 24 ÷àñîâ ïîòîì ïåðåâåñòè ê íèì è ïðîäîëæèòü ïîäãîòîâêó ê ðàäèêàëüíîé îïåðàöèè íà ôîíå ÍÌÃ.
êàêèå áóäóò ìíåíèÿ è ïðåäëîæåíèÿ? çàðàíåå áëàãîäàðåí |
#2
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Àíåìèÿ ñ ãåìîãëîáèíîì 60 íàäåþñü ëèêâèäèðîâàíà?
Åñëè èíòåðåñíî, ÷òî äóìàþò çäåñü: Consequently, we do not recommend the use of drug-coated stents for the vast majority patients with cancer, including for the treatment of acute MI or stable CAD. Èç Treatment of myocardial ischemia and myocardial infarction in patients with cancer. Therapy Insight: management of cardiovascular disease in patients with cancer and cardiac complications of cancer therapy. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] è åñëè ðåøèòåñü, òî áóäüòå ãîòîâû: Acute Coronary Stent Thrombosis in Cancer Patients: A Case Series Report [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#3
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åùå ðàçìûøëåíèÿ î õèð. âìåøàòåëüñòâå ïî ëþáîìó ïîâîäó ïîñëå ñòåíòèðîâàíèÿ çäåñü:
Coronary Stents and Noncardiac Surgery: Current Clinical Challenges and Conundrums [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#4
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àíåìèþ ñîõðàíÿåòñÿ, êðîâü íå êàïàëè ââèäó ïîëíîñòüþ ñòàáèëüíîãî ïàöèåíòà. Îáù àíàëèç êðîâè ñ íèçêèìè ïîêàçàòåëÿìè äëÿ ìåíÿ áûë ñþðïðèçîì. Ïàöèåíò âñåñòîðîííå áûë îñìîòðåí ïðèçíàêîâ êðîâîòå÷åíèÿ íåò. Äàëüøå îáñëåäîâàí. Ñïàñèáî çà ññûëêè. ïðîáëåìû êîòîðûå ìîãóò áûòü ÿ ïðåêðàñíî îñîçíàþ.
èíòåðåñóþò êîììåíòàðèè èç ïðàêòèêè. |
#5
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òî åñòü êîììåíòàðèè èç ïðàêòèêè çà ðóáåæîì Âàì íåèíòåðåñíû? È êàêîé ìèíèìóì ãåìîãëîáèíà äîëæåí áûòü ïðè ïîäãîòîâêå ê ñòåíòèðîâàíèþ èëè ïîëîñòíîé îïåðàöèè òîæå?
A retrospective database review of 310,311 veterans >65 years of age undergoing non-cardiac surgery evaluated the association of preoperative anemia with mortality or cardiac events [16]. The adjusted odds of death or cardiac events correlated inversely with the preoperative hematocrit. Even mild anemia (HCT 36.0 to 38.9) was associated with a 10 percent increase in events; this rose to a 52 percent increased risk with more severe anemia (HCT 18.0 to 20.9).
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#6
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ó ïàöèåíòà àáñîëþòíûå ïîêàçàíèÿ ïî îíêîëîãèè, äëÿ ïîâûøåíèÿ % âûæèâàåìîñòè ïàöèåíòó íóæíî ðåøèòü ïðîáëåìó ïî ÈÁÑ. ïåðåëèâàíèåì êðîâè ìîæíî äîáèòüñÿ êðàòêîâðåìåííîãî óëó÷øåíèÿ öèôð â àíàëèçàõ íî è åùå êðîâîòå÷åíèÿ èç îïóõîëè.
ïðàêòè÷åñêèå ñîâåòû ïî âåäåíèþ ìîæåòå äàòü? |
#7
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Öèòàòà:
PS. Íåïîíÿòíà òàêòèêà 24-÷àñîâîãî ââåäåíèÿ Íà (íåôðàêöèîíèðîâàííûé ãåïàðèí?) äëÿ ÷åãî? Èëè ýòî íèòðàòû? = òîò æå âîïðîñ |
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#8
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Åñëè ïàöèåíò ñòàáèëåí ñ òàêèì ãåìîãëîáèíîì è êðèòè÷åñêèì ñòåíîçîì, òî êîððåêöèÿ àíåìèè è ÆÄ è íà óäàëåíèå îïóõîëè, åñëè è èíòðà/ïîñëåîïåðàöèîííî ïðîãíîç ïàöèåíòà ïî ðàêó òàêæåîïòèìèñòè÷åñêèé, ïëàíîâîå ñòåíòèðîâàíèå â ïîäõîäÿùèå ñðîêè; åñëè îíêîëîãè òàêèå îò÷àÿííûå, ÷òî âîçüìóò ïàöèåíòà íà îïåðàöèþ íà äâîéíîé àíòèàãðåã. òåðàïèè (ÍÌà â ýòîé ñèòóàöèè êàê è ïåñîê - ïëîõàÿ çàìåíà îâñó), òî ìîæåòå ñòåíòèðîâàòü è äî îïåðàöèè; åñëè Âû áåññòðàøíû è ãîòîâû íåñòè ïîëíóþ îòâåòñòâåííîñòü çà ÿòðîãåííûé òðîìáîç ñòåíòà, â ïåðèîä, êîãäà ïàöèåíòó îòìåíÿò äîëæíóþ ÄÀÒ, à çà÷åì-òî ïåðåâåäóò íà ÍÌà (õîòÿ ìîãó ïðåäïîëîæèòü, ÷òî õèðóðãàì âñå åäèíî: ÷òî ÄÀÒ, ÷òî ÍÌÃ, ÷òî êóðàíòèë - ïðèìåðíî îäèíàêîâûå ëåêàðñòâà äëÿ ðàçæèæåíèÿ êðîâè). Âñòðå÷íûé âîïðîñ - íà ôîíå ïîëíîé äîçû ââåäåíèÿ Íà ó ïàöèåíòà ñ òÿæåëîé àíåìèåé íà÷èíàåòñÿ îáèëüíîå êðîâîòå÷åíèå èç îïóõîëè, ÷òî ñòàíåòå äåëàòü?
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#9
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Ìîæåò áûòü, òàê Âàøèì õèðóðãàì-îíêîëîãàì áóäåò ïîíÿòíåå:
Cancer surgery is considered low or intermediate cardiac risk so revascularization before surgery is needed only in exceptional circumstances. Drug-eluting stents pose special problems and should be avoided. Even bare metal stents may have a higher long-term risk of stent thrombosis in the cancer patient. --- Prog Cardiovasc Dis. 2010 Sep-Oct;53(2):149-56. Managing coronary artery disease in the cancer patient.
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#10
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íã - íåôðàêöèîíèðîâàííûé ãåïàðèí, ïîñëå ñòåíòèðîâàíèÿ íà 18-20 ÷àñîâ äî îïåðàöèè íà æåëóäêå, åãî ïðîùå êîíòðîëèðîâàòü.
îíêîëîãè íàñòàèâàþò íà ñòåíòèðîâàíèè ïîä ïðèêðûòèåì ÍÌà è âñå. Íà ôîíå èñïîëüçîâàíèÿ ÍÌà îíè ãîòîâû âçÿòü åãî â îïåðàöèîííóþ è ïðîäîëæèòü ââåäåíèå ïîñëå îïåðàöèè, ñ 3 äíÿ ïîñëå ðàäèêàëüíîé îïåðàöèè óæå êëîïèäîãðåëü ê ñîæàëåíèþ ìû íåñêîëüêî ñêîâàíû â âîçìîæíîñòÿõ èç çà ðÿäà ñîáûòèé, íà ñåé÷àñ êàê îêàçàëîñü äàæå íå÷åì êîððåêòèðîâàòü àíåìèþ, ââèäó îòñóòñòâèÿ êðîâè((( |
#11
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#12
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Êîàãóëèðîâàòü ÷òî - êðîâÿùóþ îïóõîëü â ïðîñâåòå æåëóäêà ÷åðåç ÔÃÄÑ? À åñëè êðîâèòü íà÷íåò èç íåå â áðþøíóþ ïîëîñòü - êóäà êîàãóëÿòîð ïðèëîæèòå? Íåò êðîâè äëÿ òðàíñôóçèè: ïîêà êîàãóëÿòîð ðàçîãðååòå - ïàöèåíò áóäåò óæå ìåðòâ; åñëè ó ïàöèåíòà ãåìîãëîáèí 60, òî èìåííî èç îïóõîëè è øëî êðîâîòå÷åíèå âñå åòî âðåìÿ áåç âñÿêîãî íåôðàêö. ãåïàðèíà, ñ ãåìîãëîáèíîì ìåíåå 50 ïîãèáàåò êàæäûé 4-ûé ïàöèåíò â ïîñëåîïåð. ïåðèîäå, íóæåí ëè ïàöèåíòó íà ïàìÿòü ñòåíò åñëè ó íåãî âñå øàíñû íå ïåðåæèòü áëèæàéøóþ íåäåëþ-äâå? Ìîæåò, îíêîëîãè ïîíèìàþò, ÷òî ïàöèåíò îáðå÷åí â òåõ ìåä.óñëîâèÿõ, êîòîðûõ Âû ðàáîòàåòå, íî èì áû õîòåëîñü ÷òîá âèíà åãî ñìåðòè ëåæàëà íà Âàñ?
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#13
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 äîïîëíåíèå ê ìíåíèÿì óâàæàåìûõ ó÷àñòíèêîâ.
Åñòü äîñòàòî÷íî ñâåæèé êîíñåíñóñ SCAI Expert Consensus Statement: Evaluation, Management, and Special Considerations of Cardio-Oncology Patients in the Cardiac Catheterization Laboratory 2015. Èç ïðàêòè÷åñêèõ ñîâåòîâ îòòóäà: - For cancer patients who are excellent candidates for both access types, the radial artery is preferred. - The use of smaller sheath sizes, prompt removal of sheaths and early ambulation is recommended. - A lower dose of intra-arterial or intravenous unfractionated heparin at a dose of 50 U/kg or 3.000 units is recommended for cancer patients with thrombocytopenia and platelet count <50k undergoing cardiac catheterization via radial access. - For cancer patients with an acceptable prognosis, the general revascularization criteria for appropriate use must be carefully evaluated and only the most appropriate indications (scores 7 and above) should be considered - For cancer patients with an expected survival <1 year, percutaneous revascularization may be considered for patients with acute STEMI and high-risk NSTEMI. For patients with stable angina, every effort must be made to maximally optimize medical therapy before resorting to an invasive strategy. This approach must include addressing other cancer-related comorbidities that potentially exacerbate ischemia, such as ane- mia, infection, hypoxia, etc. Should the patient continue to experience persistently severe angina (CCS Class III or IV), consideration may be given to percutaneous revascularization as a palliative option. - Balloon angioplasty should be considered for cancer patients who are not candidates for DAPT (Platelets <30,000/mL) or when a non-cardiac procedure or surgery is necessary as soon as possible. - BMS should be considered for patients with platelet counts >30,000/ mL who need a non-cardiac procedure, surgery or chemotherapy which can be postponed for >4 weeks. - Newer generation DES should be considered for patients with platelet counts >30,000/mL who are not in immediate need for a non-cardiac procedure, surgery or chemotherapy. - Attempts should be made to avoid bifurcation and overlapping stents, both of which increase the risk of ST. High pressure (>16 atm), non-compliant bal- loon inflations and the use of IVUS or optical coher- ence tomography (OCT) is recommended to assure adequate stent expansion. - When urgent surgery is needed shortly after PCI, at least one antiplatelet agent should be con- tinued if at all possible. If oral antiplatelet agents must be discontinued, a short acting intravenous IIb/IIIa re- ceptor blocker could be considered until shortly before non-cardiac surgery; however, data are non-existent and this approach remains controversial. Clopidogrel should be restarted after surgery with a loading dose of 300 mg. - When antiplatelet therapy must be stopped due to gastrointestinal bleeding, the cardiac complica- tion rate after PCI increased from 2.4% to 5.8%. Initial treatment with balloon angioplasty followed by delayed stenting after recovery from cancer surgery may be an alternative, but this option has less predictable results. È ìîå íè÷åì íå ïîäêðåïëåííîå ìíåíèå.  óñëîâèÿõ âûñîêîãî ðèñêà êðîâîòå÷åíèÿ èç îïóõîëè è íåâîçìîæíîñòè õèðóðãèè äî ÐÒÑÀ ïîäóìàòü î âûïîëíåíèè ýìáîëèçàöèè çîíû îïóõîëè. Èëè ïî êðàéíåé ìåðå áûòü ãîòîâûìè åå áûñòðî ñäåëàòü (îïðåäåëèòüñÿ ñ àíàòîìèåé, ðàñõîäíèêîì, äîñòóïîì çàðàíåå). |
#14
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Íàøà òàêòèêà (åñòåñòâåííî, íà îñíîâàíèè ýâèäåíñà):
1. Âîññòàíîâèòü êðàñíóþ êðîâü. 2. Ñòåíòèðîâàíèå ñòåíòîì, ïîêðûòûì ýâåðîëèìóñîì èëè çîòàðîëèìóñîì. 3. Îòñðî÷èòü îïåðàöèþ íà 1 ìåñÿö 4. ÄÀÀÒ 1 ìåñÿö. 5. Ìîíîòåðàïèÿ àñïèðèíîì çà 3-5 äíåé äî îïåðàöèè. 6. Âîññòàíîâèòü ÄÀÀÒ ïîñëå îïåðàöèè òàê ðàíî, êàê âîçìîæíî ÷åðåç íàãðóçî÷íóþ äîçó â 300. Æåëàòåëüíî â äåíü îïåðàöèè. 7. Áîÿòüñÿ Ïðîñüáà î çàìåíå àíòèàãðåãàíòîâ íà àíòèêîàãóëÿíòû ÷àñòàÿ ïðîñüáà õèðóðãîâ. ÊÀÒÅÃÎÐÈ×ÅÑÊÈ ÍÅÄÎÏÓÑÒÈÌÎ.
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Àáóãîâ Ñåðãåé Àëåêñàíäðîâè÷. Ðîññèéñêèé Íàó÷íûé Öåíòð Õèðóðãèè èì. àêàäåìèêà Á.Â. Ïåòðîâñêîãî. |
#15
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Ïðî÷èòàë â óïîìÿíóòîì êîíñåíñóñå ïðî áàëëîííóþ àíãèîïëàñòèêó êàê âîçìîæíóþ îïöèþ ó îíêîáîëüíûõ. Èíòåðåñíî. Îñîáåííî êîãäà åñòü íîâûå ñòåíòû, íå òðåáóþùèå äëèòåëüíîé ÄÀÀÒ, î êîòîðûõ íàïèñàë Ñåðãåé Àëåêñàíäðîâè÷.
À ñåé÷àñ ÷èòàþ ïðî øâåäñêèé êîðîíàðíûé ðåãèñòð. 6-ëåòíèå ðåçóëüòàòû âñåõ èíòåðâåíöèé â ñòðàíå ñ 2006 ïî 2010 ãîäû. Íà ïî÷òè 15 òûñÿ÷ ïëàíîâûõ êîðîíàðíûõ àíãèîïëàñòèê 9,8% âìåøàòåëüñòâ áåç ñòåíòîâ. Áîëüøå ÷åì ïðè ÎÊÑàõ. |