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#31
05.12.2005, 08:33
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Ïðè ïàíêðåàòèòå, åñëè ïàöèåíò íå ëåòèò íà ñòîë "ñòðåìèòåëüíûì äîìêðàòîì" îí ïîñòóïàåò êàê ïðàâèëî íà ìåäèöèíó (áóäü òî èíòåíñèâíàÿ òåðàïèÿ, èëè îáû÷íûé ýòàæ). Êëþ÷åâîé ìîìåíò - áûñòðàÿ îöåíêà ðèñêà (Ðàíñîí, Áàëòàçàð). Åñëè èìååì äåëî ñ âûñîêèì ðèñêîì ïî Áàëòàçàðó, òî äàëåå ñèòóàöèÿ îïðåäåëÿåòñÿ ñòåïåíüþ àãðåññèâíîñòè õèðóðãîâ è èëè ðàäèîëîãîâ. Îáû÷íî ñòàðàåìñÿ ñíà÷àëà ïîïðîáîâàòü äðåíèðîâàòü ïîä êîíòðîëåì ÊÒ. Êñòàòè ñàì ïàðó ðàç äåëàë ñ ðàäèîëîãîì. Æäåì ÷òî âûðàñòàåò, ñìîòðèì ÷óâñòâèòåëüíîñòü, ëå÷èì èçî âñåõ ñèë èìïèðè÷åñêè (èìåïåíåì èëè êîìáèíàöèÿ ëåâîôëîêñàöèíà è ïèðåðî-òàçî) è ñ èíòåðåñîì ÷èòàåì åæåäíåâíûå çàïèñè õèðóðãè÷åñêîé êîìàíäû. Êñòàòè, ïðî ðàííåå ýíòåðàëüíîå ïèòàíèå äîâîëüíî èíòåðåñíûå äàííûå.
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#32
05.12.2005, 08:47
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Öèòàòà:
Öèòàòà:
Öèòàòà:
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#33
05.12.2005, 15:37
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Öèòàòà:
Ñ óâàæåíèåì.
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#34
05.12.2005, 16:06
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Öèòàòà:
Öèòàòà:
 1. Isenmann R, Runzi M, Kron M, Kahl S, Kraus D, Jung N, Maier L, Malfertheiner P, Goebell H, Beger HG; German Antibiotics in Severe Acute Pancreatitis Study Group. Prophylactic antibiotic treatment in patients with predicted severe acute pancreatitis: a placebo-controlled, double-blind trial. Gastroenterology. 2004 Apr;126(4):997-1004. 2. Nathens AB, Curtis JR, Beale RJ, Cook DJ, Moreno RP, Romand JA, Skerrett SJ, Stapleton RD, Ware LB, Waldmann CS. Management of the critically ill patient with severe acute pancreatitis. Crit Care Med. 2004 Dec;32(12):2524-36. Öèòàòà:
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#35
05.12.2005, 19:20
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Öèòàòà:
Öèòàòà:
Öèòàòà:
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#36
05.12.2005, 23:00
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Öèòàòà:
íóæåí ëàïàðîöåíòåç,êàê ìèíèìóì. Åñëè Âû, ïðè ëàïàðîöåíòåçå ïîëó÷èëè õàðàêòåðíîå "àìáðå" , êóäà Âû â ðîññèÿíèè äåíåòåñü, áóäåòå äåëàòü ëàïàðîòîìèþ, è äðåíèðîâàòü "ñàëüíèêîâóþ ñóìêó" ,øëàíãàìè ñàìîãî áîëüøîãî ðàçìåðà.Ïðîãíîç âûæèâàíèÿ,ïî- ìîåìó, çàâèñèò îò âðåìåíè íà÷àëà çàáîëåâàíèÿ.Åñëè íà 2-å ,3-å ñóòêè êëèåíò ïîñòóïàåò, åìó íè÷åãî íå ïîìîæåò ,ñêîðåå âñåãî. À åñëè ÷åðåç ÷àñû , òî è ñîìàòîñòàòèí õîðîø. Õîòÿ áîìæåé è ãëþêîçî-íîâîêàèíîâîé ñìåñüþ âûòàñêèâàåì.
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#37
05.12.2005, 23:18
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Öèòàòà:
Öèòàòà:
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#38
05.12.2005, 23:19
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×òî äðåíèðóåòå?
In grade D or E fluid collection. If sterile - good, if growing - bug the surgeons one more time. Imepenem is not better then others positive data is present for several combinations. Early antibiotic treatment in acute necrotising pancreatitis. Sainio V; Kemppainen E; Puolakkainen P; Taavitsainen M; Kivisaari L; Valtonen V; Haapiainen R; Schroder T; Kivilaakso E Lancet 1995 Sep 9;346(8976):663-7. cefuroxime (4.5 g/day intravenously) better. Mortality was higher in the non-antibiotic group (seven vs one in the antibiotic group; p = 0.03). Four of the eight patients who died had cultures from pancreatic necrosis positive for Staph epidermidis. We conclude that cefuroxime given early in necrotising pancreatitis is beneficial and may reduce mortality, probably by decreasing the frequency of sepsis. Prophylactic antibiotics in treatment of severe acute alcoholic pancreatitis.Delcenserie R; Yzet T; Ducroix JP Pancreas 1996 Aug;13(2):198-201. Infectious complications currently account for 80% of deaths from acute pancreatitis. The aim of this study was to evaluate the necessity for prophylactic antibiotics in patients with severe acute pancreatitis. Twenty-three consecutive patients suffering from acute alcoholic pancreatitis with computed tomography demonstrating two or more fluid collections were randomly assigned to one of two groups receiving either nonantibiotic treatment or prophylactic antibiotics (ceftazidime, amikacine, and metronidazole for 10 days). Sepsis was always diagnosed by positive cultures. Seven episodes of severe sepsis occurred (pancreatic infection and septic shock) in the nonantibiotic group, and no infection occurred in the prophylactic antibiotic group (p < 0.03). In conclusion, the use of prophylactic antibiotics in severe alcoholic acute pancreatitis significantly reduces the incidence of severe infection. Zosyn (ïèï-òàçî) íè ñ ÷åì êîìáèíèðîâàòü íå íóæíî, ó íåãî è òàê ñïåêòð îãðîìíûé. Íî Èìåïåíåì åäèíñòâåííûé àíòèáèîòèê ñ äîêàçàííîé ýôôåêòèâíîñòüþ ïðè ïàíêðåàòèòå. I agree that Zosyn alone should be ok but the problem of double coverage is open to discussion. In our hospital we only have 75% Pseudomonas sensitivity to Zosyn and about 70% to Levaquin. There was only one strain of Pseudomonas resistent to both in the last 2 years of monitoring. Out of 10 severe necrotising pancreatitis in our settings about 3 are growing resistant pseudomonas. This is because of the high antibiotic pressure in this community. Personally i do not know any ID doc who would leave Grade E pancreatitis with no AB coverage. In view of conflicting evidence lets give the patients benefit of the doubt.
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#40
05.12.2005, 23:43
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Öèòàòà:
Êñòàòè, Âû îïðåäåëÿåòå óðîâåíü ÑÐÏ? To Alex_md: Ñ Àáõ ñîãëàñåí.
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#44
06.12.2005, 00:09
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Öèòàòà:
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#45
06.12.2005, 15:37
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Êñòàòè â Ðîññèè õîðîøîé ÓÇÈ àïïàðàò â óìåëûõ ðóêàõ äóìàþ áóäåò íå õóæå ÷åì ÊÒ, êîòîðûé íå âñåãäà äîñòóïåí è âñåãäà äîñòóïåí íå 24 ÷àñà ( íå ñìîòðÿ íà äàííûå èññëåäîâàíèé). Ëè÷íî çíàþ íåñêîëüêèõ õèðóðãîâ, êîòîðûå ñìîãóò ïàíêðåàñ, äà è âîîáùå îñòðûé æèâîò â ðåàëüíîì âðåìåíè îñìîòðåòü òàê, ÷òî íèêàêîé ÑÒ è ýíäî-ÓÇÈ íå ïîíàäîáèòñÿ.
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Ëèíåéíûé âèä
