drenajul pericardic percutan in pericardita neoplazica
DESCRIPTION
rolul ultrasonografiei in ghidajul pericadocentezei si drenajului pericardic percutan la pacientii cu pericardita neoplazicaTRANSCRIPT
DRENAJUL PERICARDIC DRENAJUL PERICARDIC PERCUTAN GHIDAT PERCUTAN GHIDAT
ECOGRAFIC IN ECOGRAFIC IN PERICARDITA CRONICA PERICARDITA CRONICA
NEOPLAZICANEOPLAZICA
Alexandru AndritoiuAlexandru Andritoiu, Aurelia Resceanu, Cristian Silosi, Paul Demetrian, Corina Drighiciu, Florin Robescu
Sp. Militar CraiovaSp. Militar Craiova
IndicatiiIndicatii
• Pericardita cronica• Tamponada subacuta
Scop
• Diagnostic
• Terapeutic - hemodinamic
• Drenaj evacuator
TehnicaTehnica
• Trusa drenaj• Ecograf• Monitorizare ATI :
TA, AV, ECG, SaO2
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
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
Pericardocenteza(tamponada cardiaca)(tamponada cardiaca)
PericardocentezaGhidaj US
Anestezie locala(xilina 1%)
Pericardita hemoragica !
Ex laborator – lichid pericardic
• R. Rivalta (++)• Proteine 5.4 g/ml• CEA –slab pozitiv !?• Culturi negative (aerobe);• Frotiu: inflamator; fara
atipii celulare!
Drenaj pericardic continuupercutan sub ghidaj US
Control US
Fi.A paroxistica
Rx (control 48 ore)
CT
2. Caz clinic
• CS, F, 80 ani
• Pericardita cronica
• Insuf. Card cls 2/3
Rx C- PRx C- P
CT
ECGECGRS, T neg. D1, D2, aVL, V4-V6
EcocardiografieEcocardiografie
Zoom
Tumora pericardica?
Zoom
CTCT
Examene biologiceExamene biologice
• VSH: 41-99 mm/h
• Proteina C reactiva - pozitiva
Diagnostic de etapaDiagnostic de etapa
• Pericardita cronica-hemoragica
• Mezoteliom pericardic ?
Drenaj pericardic 14 Drenaj pericardic 14 zilezile
Adm. Intra-pericardicaAdm. Intra-pericardica
• Cisplatinum 10mg x 5 z
• Gentamicina 80 mg
Suport ATI
Punctie pericardica
Dilatator pe fir-ghid
Insertie cateter
Monitorizare ECG, TA, SaO2
Control Rx
Contrast intra-pericardic
Reconstructie 3D-CT
Lichid pericardic – z 12
Benzi de fibrina flotante
Benzi de fibrina
Examen lichid pericardic
BIOCHIMIE
Proteine: 5.1 g/dL
LDH 903 UI/L
CRP 0.2 mg/dL
Glucoza 82 mg/Dl
CEA negativ
CITOLOGIEFrotiu 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
Cispatinum
5 x 10 mg/zi - intrapericardic
Caz clinic 3
• ILIE CONSTANTIN, 53 ani, Craiova
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)
Ex. obiectivEx. 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)
ECG la prezentare
10.10.2013
US/10.10.2013US/10.10.2013
CervicalaCervicala• Bloc adenopatic stg
Eco tiroidaEco tiroida• Noduli benigni bilateral
Eco-cord-relatii normale
Eco Abdmen• Colecist exclus chirurgical• Ficat, pancreas, splina,
RD, RS, vezica urinara, prostate-normale
Diagnostic de etapaDiagnostic de etapa
In obs: Neoplasm bronho-pulmonar
Elemente:Elemente:
• Fumator (+++)
• Ereditate: tatal decedat de neo pulmonar
• Voce ragusita
• Adenopatie tumorala (maligna)
14.10.2013/ CT toracicCT toracic
• Laringe asimetric-formatiune infiltrativa lateral stg+bloc adenopatic latero-cerv stg
• Pulmon, mediastin, pleura-normale
Dr. Demetrian Paul
15.10.2013Laringoscopie endoscopicaLaringoscopie endoscopica
• Paralizie de coarda vocala stg
• Infirma neoplasmul laringian
Dr Cheita Nicolae
Evolutie intraspitaliceasca
• Dureri atroce cervical stg
• Scadere ponderala (facies malign)
• Tuse seaca
• Dispnee progresiva
• Ziua - prabusire TA (TAS 70-80 mmHg)
27.10.2013/Eco cord27.10.2013/Eco cord
• Pericardita (revarsat abundent > 3 cm anterior)
• Semne de tamponada sub.acuta
ECG (pericardita)
Complexe hipovoltate
Atitudine terapeuticaAtitudine terapeutica
• Punctie pericardica• Drenaj pericardic
• Biopsie ganglionara (supra-clavicular stg)
Dr. Andritoiu A, Dr Silosi C, Dr. Resceanu Aurelia
Anestezie generalaAnestezie generala
28.10.2013/Punctie pericardica28.10.2013/Punctie pericardica
Drenaj pericardic percutanDrenaj pericardic percutan(tehnica Seldinger)ghidaj ecografic
Ex. Citologic (lichid pericardic)
• Frecvente hematii
• Frecvente mezotelii (mezoteliom pericardic?)
• Rare leucocite
• Aspect ,,reactiv,,
• Fara celule maligne!
Dr. Drighiciu Corina
30-50% din cazuri-citologie negativa!!!
30.10.2013/ Repeta CT toracic Repeta CT toracic
• Pericardita• Pleurezie bilaterala• Colabare lob inf stg• Adenopatie • Tum hilara
CT – cateter pericardicCT – cateter pericardic
EvolutieEvolutie
• Aspirat continuu• >100 ml/zi• Refacere rapidaRefacere rapida• Aspect hemoragic
• TratamentTratament• AB• HSHC• Etamsilat• Suport inotrop pozitiv• Antialgice• Oxigen
TA 100/65 mmHg, AV 90 bpm, SaO2 85-92%
Chimioterapie localaChimioterapie locala
• CisplatinCisplatin• 3 zile• Fara rezultat favorabil
10 mg+20 ml Na Cl (dilutie)/zi
ToracentezaToracenteza
• 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
• VSH 30-36 mm/hVSH 30-36 mm/h• Le 11.790/mmcLe 11.790/mmc• Hb 15.6-11.4 g/dLHb 15.6-11.4 g/dL• Ht 43-31%Ht 43-31%• Fibrinogen 457-471 mg/dLFibrinogen 457-471 mg/dL• CRP 7.9 mg/dLCRP 7.9 mg/dL• TGO 14-91 UI/LTGO 14-91 UI/L• TGP 14-375 UI/LTGP 14-375 UI/L• Ac. bK negativi• Mb negativ• CPK-MB 23 UI/L• LDH 432 UI/L
Biochimie (lichid pericardic)Biochimie (lichid pericardic)
• Proteine g/dL• Glucoza 62 mg/dL• LDH 2933 UI/L• R. Rivalta Poz (+++)
Oncogene (lichid pericardic)Oncogene (lichid pericardic)
Incidente/Complicatii
• Infectie cutanata
• Blocajul cateterului
• Pneumopericard
• Pneumotorax
• Aritmii
• Deces
CisplatiniumCisplatiniumEfecte 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.
Intrapericardial Cisplatin treatment prevents effectively Intrapericardial Cisplatin treatment prevents effectively the recurrence of neoplastic pericardial effusionthe recurrence of neoplastic pericardial effusion
B. Maisch, S.Pankuweit, H. Rupp, A. Ristic,
Conclusion: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