~A Boy Always Young~

2011年7月20日 星期三

complication of TAE


Complication of Transcatheter Arterial Embolization
1.      Liver injury:
--Acute liver failure
--liver abscess
--intrahepatic biloma
--liver infarction
--multiple intrahepatic aneurysm
2.      Extrahepatic injury
--cholecystitis or GB infarction
--splenic infarction
--GI mucosa lesion
--tumor rupture
--variceal bleeding
3.      Other
--dissection or perforation of celiac a.
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cirrhosis

liver cirrhosis complication:
1.portal vein HTN
2.ascites
3.SBP
4.liver failure
5.hepatoma


decompensated cirrhosis(Child B, C):
1.Alb decrease
2.Bil increse-->jaundice if >2
3.Ascites
4.PT prolong
5.Encephalopathy
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2011年7月14日 星期四

HCC


HCC診斷:
1.      lession>2cm
2.      AFP>200
3.      兩種image

HCC治療:
A.      Child A, B
a.      single
1.      移植:<6.5 cm
2.      開刀:ascites OKBil<2if Child A
      ICG<15
可大範圍切除,否則須再評估
3.      局部(PEITRFA)禁忌如下
a.
多於 3個、大於5 cmbeside vital organs(e.g. Gall bladder--for PEIT and RFA or main trunk of blood vessel--for RFA)PLT<8 or prolonged P>5
4.      TAE禁忌如下:
Absolute
a.      Total occlusion of the portal trunk
b.      Presence of encephalopathy
c.       Serium bilirubin level >3.0 mg/dL
d.      uncooperative patient
Relative
a.      Uncontrollable ascites
b.      Recent variceal bleeding
c.       Portal vein occlusion in right main branch
d.      Arterio-Venous shunt or Arterio-Portal shunt
e.      AST> 300 U/L, or ALT> 300 U/L or LDH >425 U/L
f.        Thrombocytopennia(platelet<50000/uL)
g.      Coagulopathy (PT prolongation > 3 sec. or INR > 1.5 )
b.      Multiple
1.      移植:<4cm
2.      開刀:<3顆、<4.5cm
3.      局部:<3顆、<5cm
4.      TAE
B.      Child C
a.      No Portal Invasion
1.      移植:<4cm
2.      局部:<3顆、<5cm
3.      TAE
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Review of Systems


l   General: body weight change, weakness, fatigue, fever, chills
l   Skin: rashes, lumps, sores, itching, dryness, color change, change in hair or nails
l   Head: headache, head injury
l   Eye: vision, glasses or contact lenses, pain, redness, excessive tearing, double vision, glaucoma cataracts
l   Nose and sinuses: frequent colds, nasal stuffiness, discharge, itching hay fever, nose bleeds, sinus trouble
l   Neck: lumps in the neck, swollen glands, goiter, pain or stiffness
l   Breast: lumps, pain or discomfort, nipple discharge, self-exam
l   Cardiovascular: chest pain, high blood pressure, rheumatic fever, heart murmurs, orthopnea, paroxysmal nocturnal dyspnea, edema
l   Respiratory system: cough, sputum, hemoptysis, wheezing, asthma, bronchitis, ephysema, pneumonia, Tuberculosis, pleurisy
l   Endocrine: thyroid trouble, heart or cold intolerance, excessive sweating, diabetes, excessive thirst or hunger, polyuria
l   Hematologic: anemia, ease bruising or bleeding, post transfusions, possible reaction
l   Lympahtic: lymphadenopathy:  location:    size:      character:
l   Gastrointestinal: trouble swallowing , heat burn , appetite , nausea , vomiting , regurgitation , vomiting of blood , indigestion ,  color and size of stools , change in bowel habits , rectal bleeding or a tarry stools , hemorrhoids , constipation , diarrhea , abdominal pain , food intolerance , hepatitis , jaundice , liver or gallbladder disease , excessive belching or passing of gas
l   Genitourinary: frequent of urination , polyuria , nocturia , burning or pain on urination , hematuria , urgency , reduced caliber or force of the urinary stream , hesitancy , incontinence , urinary infection , stones
l   Musculoskeletal: muscle or joint pain , stiffness , arthritis , gout , backache
l   Rheumatologic: hair loss , malar rash , discoid rash , oral ulcer , athralgia , dry eye , dry mouth
l   Neurologic: consciousness change , fainting , blackouts , seizures , weakness , paralysis . numbness , tingling , tremors or other involuntary movements.
l   Psychiatric: nervousness , tension , mood change including depression , memory loss , auditory hallucination , visual hallucination , involuntary movement
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2011年7月13日 星期三

GI Bleeding





GI bleeding: 80%UGIB會自動止血
常見原因:
a.       消化性潰瘍 (胃或十二指腸): 47-79%
b.      胃糜爛: 6-30%
c.       食道靜脈曲張: 8-16%
d.      其他 (食道炎,十二指腸糜爛, Mallory-Weiss裂傷, 腫瘤, 血管病變)
重要病史:
a.       使用 Aspirin, Plavix, Coumadine ,NSAID, 酒精
b.      肝病史,先前食道靜脈曲張出血
c.       潰瘍病史,心窩灼熱, 吞嚥困難, 體重減輕;
d.      腹部主動脈瘤或血管移植術後

Hx taking
a.       黑、暗紅、鮮紅?
b.      PUD with bleeding, cirrhosis, EV bleeding
c.       NSAIDs, Aspirin, Plavix, Coumadin
d.      Uremia, heart failure, COPD
LAB
a.       CBC/DCplateletPTPTT
b.      Hemodynamic evaluation, Digital examination
    
Treatment for Active UGI bleeding
Volume expansion à arrange PES à Nexium 2 vials ( 80 mg ) IVB 20~30 minutes st à Continuous iv infusion (8 mg/hr) × 3 days (4~5 vials/day) à if no active bleeding sign à 1 vial Q12h
90~95% re-bleeding,都在 3天內發生,所以用3
pH > 4 is a critical threshold for gastric pepsin activitypH > 6 is needed to maintain platelet aggregation,所以用Losec or Nexium


何時懷疑EVB
a.       Liver cirrhosis, EV bleeding history
b.      HBV or HCV without regular F/U
c.       Heavy alcoholism
d.      Thrombocytopenia
e.       PT prolong (INR>1.3~1.5)
f.       U/A Bil > (+) à jaundice
g.      Leg edema, Ascites, spider nevus

Liver cirrhosis with portal hypertension 導致 EV or GV bleeding
a.       Glypressin 2 vials iv bolus st à 1 vial Q4~6 hrs
b.      Volume expansion, blood transfusion , PES , iv Antibiotics
Ciproxin 2Amp st & Q12 hrs
或者
Cefamezine 1 vial iv st & Q 6-8 hrs
加上
Augmentin 1-2 vials iv st & Q 6-8 hrs

何時要準備輸血:
a.       Platelet < 8萬,有bleeding sign
b.      PT(INR) 1.3~ 1.5,有bleeding sign
c.       PTT > 1.5~2 x,有bleeding sign
d.      目標 : Hb 8.0為原則
Uremia 患者 platelet dysfunction,不要只顧platelet count,應測bleeding time

NG適應:
a.       DDxUGI or LGI bleedingàDx rate85%+ N/S 200-500cc lavage and aspiration可達85-90%
b.      評估出血速度或開刀之可能性,但可能因 NG kinking 而誤判
c.       TxDecompression, avoid aspiration(須保持NG暢通)
NG禁忌:
a.       EV bleeding,尤其 post-EVL
b.      Dx for PPU(打Air for standing CXR

NG tube lavage乾淨代表胃無急性出血或幽門緊閉,約18% UGI Bleeding 沖洗時無血液內容物,非血液內容且含膽汁之抽取物,仍無法排除上消化道出血

PES禁忌:unstable Airway, poor cooperation, Peritonitis, R/O PPU

胃鏡意義及處理:
Active bleeding signà need therapeutic endoscopy intervention
a.       Spurting (or pulsation bleeding): continuous bleeding rate 80~100 %
b.      Non-bleeding visible vessel (NBVV): visible vessel with bloody clots      (vessel exposure, but no active bleeding sign) Re-bleeding rate 40~50 %
c.       Oozing ulcerative base without visible vessel: continuous bleeding rate 30 %
d.      Adherent clot : Bloody clots (dark/fresh) without visible vessel Re-bleeding rate 25 %
SRH (Stigmata of recent hemorrhage)à keep  observation
a.       Visible vessel only ( clean base , no oozing ): Rebleeding rate 15 ~ 20 %
b.      Hematin/dark bloody base( no visible vessel), Flat, pigmented spot: Rebleeding rate 10%
Simple ulcer: Near no rebleeding
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2011年7月12日 星期二

IVF


甲、Holliday-Segar method
l   10kgà100ml10-20kgà50ml>20kgà20ml
乙、正常所需:
l   Na+75-175mEq/day (2 meq/kg/day)
l   K+20-60mEq/day ( 1 meq/kg/day)
--1amp=15% 5cc
,約需2-6amp
--
口服U-citrate Granules內含Potassium Citrate 30mEq/PKG--一顆Slow-K8 mEq
l   Detrose 100-150g/day (低血糖可用250g/day)
l   NPO:每天給D5W 1000cc+ 1/2Saline 1500cc,每袋各加KCL 1amp
l   速記:2000 cc Na120 meqK60 meqGlu100~150 g微血管可承受600 mosm
丙、略估輸液速度
l   15 = 1cc1/sà4cc/minà240cc/hr(大人)
l   60 = 1cc1/sà1cc/minà60cc/hr(小孩)
丁、常見輸液濃度

Osmo (mosm)
 Glu (g/L)
 Na (Cl) (meq/L)
 K (meq/L)
 D5W
 278
 50
 0
 0
 D10W
 278 X2
 50 X2
 0
 0
 D50W
 278 X10
 50 X10
 0
 0 


 Osmo (mosm)
Glu (g/L) 
Na (Cl) (meq/L)
 K (meq/L)
 N/S (0.9%)
 308
 0 
 154
 0
 1/2 N/S
 308 X1/2
 0
 154 X1/2
 0
 1/4 N/S
 308 X1/4
 0
 154 X1/4
 0
 3% N/S
 308 X 3
 0
 154 X3
 0


Osmo (mosm)
 Glu (g/L)
 Na (Cl) (meq/L)
 K (meq/L)
 D5S
 278+308=586
 50
 154
 0
 D5S1/2
 278+308X1/2=355
 50
 154X1/2=76
 0
 D5S1/4
 278+308X1/4=431
 50
 154X1/4=38
 0 


 Osmo (mosm)
 Glu (g/L)
 Na (Cl) (meq/L)
 K (meq/L)
 HCO3- (meq/L)
 L-R
 273 
 50
 130
 4
 28

    戊、常用的PPN熱量表

D5W 500ml
85 kcal
Amino-V 500ml
200 kcal
Aminoplasma 500ml
400 kcal
10% Intrafat 200ml
220 kcal
10% Intralipid 100ml
110 kcal
20% Lipovenous 250ml
500 kcal
20% Lipofundin 250ml
500 kcal
10% Glycerol 300ml
190 kcal
20% Mannitol 500ml
200 kcal


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