Drenajul peritoneal continuu ghidat ecografic

Drenajul peritoneal continuu in ascita

refractara

Alexandru Andritoiu, MDDept. Medicina Interna

www.smucraiova.ro

De evitat arterele De evitat arterele epigastrice inferioareepigastrice inferioare!!

ParacenteParacentezaza • Repeated large-volume paracentesis (4-6 L/day) • Total paracentesis (single-day hospitalization

regime)Postparacentesis circulatory dysfunction is not spontaneously reversible and is associated with a shorter time to first readmission and shorter survival.

Postparacentesis circulatory dysfunction was defined as an increase in plasma renin activity on the sixth day after paracentesis of more than 50% of the pretreatment value to a level > 4 ng.mL-1.h-1.

Albumin is the best plasma expander to prevent this complication

Plasma expanders: Haemaccell, Dextran 70

CCateterateterele tunelateele tunelate

Cateter Cateter Tenckhoff Tenckhoff

Kit de drenaj Kit de drenaj PleurX PleurX

Placement of a permanent, tunnelled peritoneal drainage catheter (PleurX) for refractory malignant and portal-hypertensive ascites in a multicentre study

G.-M. Semadeni GM et al, J Hepatology 2015 62 S381

Kit de drenaj Kit de drenaj Aspira Aspira

Kit de drenaj ASEPT

Sistemul de drenaj ASEPT:

cateter drenaj ASEPT™seringa 10ccac de insertie cu fir de ghidare 18G fir de ghidare in forma de Jintroducator de extrageretunelaradaptor linie drenaj 5 in 1linie drenaj ASEPT™ cu capacsuport cateter din spumatampoane tifon 4”x4” (10 cm x 10 cm)

280 RON

1.190 RON

Cateter Pigtail

• Pac. 69 ani • ICC cls IV-CMD • Ascita cardiaca• Cateter peritoneal

permanent (PleurX) • Drenaj la domiciliu

2-4 L ascita/sapt.

Durata drenajuluiDurata drenajului• 500-1000 mL/h• 3-4 h/zi

No drainageNo drainage: La ce te poti astepta…

Blocaj – spala cateterul cu jet de solutie salina sterila

Kinking-ul tubului de drenDrenul a iesit din cavitatea

peritoneala – inlocuiste-l cu altul nou intr-un alt loc

Caz clinic 1Caz clinic 1

• MM.. M Marianarian,, 47 ani• Diagnostic:Diagnostic:• Ciroza hepatica etanolica• Ascita voluminoasa (grad 3)• Drenaj continuu peritoneal (Seldinger)

cateter venos central

Analize laboratorAnalize laborator

TQ 19sAP 45%INR 1.39Tb 86.000 mmc

US AbdominalaUS Abdominala

Ghidaj ecograficGhidaj ecografic

Anestezie locala 10 mL Xilina 1%

Insertia firului ghidInsertia firului ghid

Insertie dilatatator pe firul Insertie dilatatator pe firul ghidghid

Insertie cateter pe firul Insertie cateter pe firul ghidghid

Control USControl US

Imediat/post-procedura Ziua a 3-a

CT AbdomenCT Abdomen

F

A

A-ascita, F-ficatSageta-dren intraperitoneal

TratamentTratament

• Diuretic (Spiroloactona 50 mg/z+Furosemid 40 mg/z)

• Albumina (i.v.)• Hepatoprotectie (Aspatofor, Arginina)• AB (Sulcef 2g/z i.v.+ Ciprofloxacin 500mg x2/z)• Drenaj continuu 7 zile (11.000 mL)

Curba greutatiiCurba greutatii

65

70

75

80

85

90

95

z 1 z 2 z 3 z 4 z 5 z 6 z 7 z 8 z 9 z 10 z 11 z 12 z 13

G (kg)

Drenaj continuu 7 zile

Caz clinic 2Caz clinic 2

P. Florea, 58 ani• Diagnostic:Diagnostic:• Ciroza hepatica vir. B+Alcool• Ascita refractara• Scor MELT: 19

Istoric

• 2012-colectectomie icter mecanic litiazic• Ciroza hepatica VHB• Biopsie hepatica intra-oper (Sp. CFR-Cva)• 1 luna post-oper-decomp. ascitica• Repetate spitalizari (ascita recurenta)• Ian-Febr. 2014: Spit. Calafat (ascita

refractara: Spirono 6 cp, Furosemid 2 cp/z)-fara rezultat!

Ex. clinicEx. clinic• Abdomen destins, in tensiune• Ascita abundenta• Circulatie colaterala P/C

Ex. biologiceEx. biologice

• Tb 167.000/mmc• TQ 22 s;• AP 36%; • INR 1.6

Cateter drenaj ascita (z 3)Cateter drenaj ascita (z 3)

Monitorizare functii vitaleMonitorizare functii vitale

Diureza < 1000 mL/zi

Drenaj 3500 mLDrenaj 3500 mL

Cefort 1g in PEV–Glucoza 5% 500 mLPEV Dextran 70-glucoza 500 mL

Curba greutatii (Kg)Curba greutatii (Kg)

83 83 83

7880 80

77.576 75 74.5

73 73 73 73 72.570

60

65

70

75

80

85

z 1 z 2 z 3 z 4 z 5 z 6 z 7 z 8 z 9 z 10 z 11 z 12 z 13 z 14 z 15 z 16

G (Kg)

Cateter peritoneal

Drenaj 1000 3500 3500 3500 4000 1800 1100 1700 1500 1500 2000 1500 1000 1500

Na 125 mmol/L Na 110 mmol/LK 5.24 mmol/L K 5.98 mmol/L

Uree 53 mg/dLCreatinina 0.9 mg/dL

Uree 90 mg/dLCreatinina 1.46 mg/dL

Uree 85 mg/dLCreatinina 1.2 mg/dL

TratamentTratament• Albumina• Aspatofort iv, Arginina, Liv 52, Silimarina• Furosemid (1/2 f im), Spironolactona 25

mg x2• Ampicilina 2 x 1 g – PEV, Ciprofloxacina

500 mg x 2, Normix 2 x 2 cp/z• Sol. Dextran 70 (glucoza), Sol. Ringer,• Pantoprazol 2x20 mg/z • Fitomenadion 2x 1f i.m.• Aspavim

Case clinic 3 P. Gheorghe, 54 ani

• Ciroza hepatica vir B –Ascita refractara• Icter• Tum hep. centrohilara (Colangiocarcinom)• VSH 52 mm/h• Tb 74.000/mmc• INR 1.34• BRT 7.5 mg/dL• CA 19-9 58u/mL (N<35)

US-Abdomen

Ficat ciroticAscitaTumora centro-hilaraDilatatii CBIH

RMN Abdomen• macronodul tumoral centro-hilar si in

segm. IV-VIII, in hipersemnal T2, hiposemnal T1, heterogen postcontrast de 6/5 cm - ce determina obstructia cailor biliare intrahepatice

Drenaj ascita

Colangiografie percutana

Drenaj bilar extern-percutan

Z-4: angiocolita, sepsis, MSOF, exitus (Acynetobacter)

ComplicatiiComplicatii

ConcluziiConcluzii

• Drenajul percutan continuu al ascitei refractare in CH poate fi o solutie terapeutica (…costisitoare!)

• Atentie la:• aspectul ascitei in zilele urmatoare• riscul de infectie, in ciuda protectiei cu

AB• monitorizarea ionogramei serice si TA