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#16
08.07.2006, 20:52
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Цитата:
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#17
08.07.2006, 20:56
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Судя по предложенным вариантам ответов, речь идет не о жировой эмболии
 Все-таки ТЭЛА. Я тоже за болюс+инфузия гепарина, так как для тромболизиса - не та тяжесть, а п/к введение - это не лечение ТЭЛА, а профилактика.
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#19
08.07.2006, 21:05
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судя по клинике -болезненость в голени, в задаче имеется в виду не жировая эмболия,а тромбоз вен голени и тЭЛА, а вот почему низкомолекулярный гепарин не может быть назначен подкожно, и не как профилактическое средство, не понимаю
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#20
09.07.2006, 01:00
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Целесообразно болюсное в/в введение , имеющее более стабильную фармакокинетику , в отличие от подкожного введения , при котором Смах в крови создается через 3-6 часов .
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#21
09.07.2006, 01:39
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То, что подкожное введение - это не то, понятно. Я все-таки склонялся к тромболизису, но раз это увеличивает риск кровотечения...
В принципе, логично, да.
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#22
09.07.2006, 09:19
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В подтверждение своих слов, что в данной ситуации возможно подкожное введение низкомолекулярного гепарина нашла метаанализ. Так как пациент не умер и имеет стабильную гемодинамику, то у него вероятнее всего субмассивная ТЭЛА. Соответствено все нижеследующее к нему применимо.
Low-molecular-weight heparin compared with intravenous unfractionated heparin for treatment of pulmonary embolism: a meta-analysis of randomized, controlled trials. Quinlan DJ; McQuillan A; Eikelboom JW Ann Intern Med 2004 Feb 3;140(3):175-83. BACKGROUND: Low-molecular-weight heparin has greatly simplified the management of deep venous thrombosis. However, for patients who present with pulmonary embolism, the role of low-molecular-weight heparin is uncertain and unfractionated heparin remains widely used. PURPOSE: To compare the efficacy and safety of fixed-dose subcutaneous low-molecular-weight heparin with that of dose-adjusted intravenous unfractionated heparin to treat acute pulmonary embolism. DATA SOURCES: The MEDLINE, EMBASE, and Cochrane Library databases were searched up to 1 August 2003. Additional data sources were manual searches of abstract proceedings and personal contact with investigators and pharmaceutical companies. STUDY SELECTION: Randomized trials comparing fixed-dose subcutaneous low-molecular-weight heparin with dose-adjusted intravenous unfractionated heparin for the treatment of nonmassive symptomatic pulmonary embolism or asymptomatic pulmonary embolism in the context of symptomatic deep venous thrombosis. DATA EXTRACTION: Two reviewers independently selected studies and extracted data on study design; quality; and clinical outcomes, including symptomatic venous thromboembolism, death, and major and minor bleeding. Odds ratios for individual outcomes were calculated for each trial and were pooled by using the Mantel-Haenszel method. DATA SYNTHESIS: Fourteen trials involving 2110 patients with pulmonary embolism met the inclusion criteria. Separate outcome data for patients with pulmonary embolism were not available from 2 trials (159 patients), leaving 12 trials for meta-analysis. Compared with unfractionated heparin, low-molecular-weight heparin was associated with a non-statistically significant decrease in recurrent symptomatic venous thromboembolism at the end of treatment (1.4% vs. 2.4%; odds ratio, 0.63 [95% CI, 0.33 to 1.18]) and at 3 months (3.0% vs. 4.4%; odds ratio, 0.68 [CI, 0.42 to 1.09]). Similar estimates were obtained for patients who presented with symptomatic pulmonary embolism (1.7% vs. 2.3%; odds ratio, 0.72 [CI, 0.35 to 1.48]) or asymptomatic pulmonary embolism (1.2% vs. 3.2%; odds ratio, 0.53 [CI, 0.15 to 1.88]). For major bleeding complications, the odds ratio favoring low-molecular-weight heparin (1.3% vs. 2.1%; odds ratio, 0.67 [CI, 0.36 to 1.27]) was also not statistically significant. CONCLUSIONS: Fixed-dose low-molecular-weight heparin treatment appears to be as effective and safe as dose-adjusted intravenous unfractionated heparin for the initial treatment of nonmassive pulmonary emboli
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#23
09.07.2006, 13:45
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Обьяснение авторов задачи:
The correct answer is B. This patient has almost certainly suffered a pulmonary embolism. All postoperative patients are at increased risk for this disorder, but orthopedic patients have a much-increased risk above that for venous thrombosis and embolism. For this reason, all of these patients are placed on aggressive prophylaxis measures postoperatively. Once present however, the best intervention to reduce 24-hour mortality is aggressive anticoagulation with intravenous unfractionated heparin at 80U/kg bolus and 18U/kg/hr infusion titrated to a PTT of 60-75. Embolectomy (choice A) is reserved for patients with pulmonary emboli who have acute right heart failure as a result. These patients have elevated jugular venous pulsations, hypotension, and tachycardia. Even when present, embolectomy, or its less-invasive option, thrombolysis (choice E), have not been shown to be efficacious in terms of mortality prevention. Clearly thrombolysis is less invasive but does carry a substantial risk of bleeding (3-10%). Starting oral warfarin (choice C) in the absence of heparin is not appropriate. The correct therapy involves a standard regimen of heparin overlapped with warfarin until an international normalized ratio (INR) of 2.0 to 3.0 is obtained on two consecutive days. This regimen is sufficient for the prevention of skin necrosis, which may occur during the initiation of warfarin therapy in patients with a deficiency of protein C. Mini-dose or subcutaneous heparin (choice D) is used for prophylaxis, not treatment. Видимо, в варианте D авторы не имели ввиду низкомолекулярный гепарин. 
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#24
09.07.2006, 13:50
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A 22-year-old college student comes to the emergency department with a severe right lower quadrant pain. She says that the pain started approximately 6 hours ago and has progressively worsened. She has no significant medical problems and her only medication is oral contraceptive pills. She is sexually active with 1 partner, her boyfriend. Her last menstrual period was 2 weeks ago. Vital signs are: temperature 37.0 C (98.6 F), blood pressure 120/70 mm Hg, and pulse is 80/min. Abdominal examination is significant for focal tenderness in the right lower quadrant. Pelvic examination reveals exquisite tenderness in the right adnexa, a closed cervical os, and clear vaginal discharge. Laboratory studies show:
B-HCG negative Leukocyte 7300/mm3 Hg 14g/dl The most likely etiology of this patient's symptoms is A. acute appendicitis B. diverticulitis C. ovarian torsion D. a ruptured ectopic pregnancy E. a tuboovarian abscess
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#25
09.07.2006, 13:53
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Ну, раз не внематочная беременность, то А - острый аппендицит.
Хотя, лейкоциты как-то низковаты.
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#28
09.07.2006, 14:32
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А last menstrual period was 2 weeks ago и еще her only medication is oral contraceptive pills... (хотя я не та Ира).
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#30
09.07.2006, 14:36
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Забыла привести обьяснение к первой задаче:
Explanation: The correct answer is A. This patient has symptomatic hypercalcemia. The most likely etiology in this patient is hyperparathyroidism. This diagnosis is made by checking PTH levels. Since her calcium is elevated, a normal or high PTH level is inappropriate and therefore would help confirm the diagnosis. Vitamin D (choice B) intoxication is typically secondary to patients taking large amounts of vitamin D (often for treatment of hypoparathyroidism). The treatment is to discontinue vitamin supplementation and recheck levels. This patient denied taking over-the-counter medications or vitamins. Ordering a TSH (choice C) is never a bad idea in a patient with a variety of vague complaints since thyroid disease is very common and because it can explain these symptoms. In this patient, you would expect to find hypothyroidism based on her symptoms but an elevated serum calcium is more likely explained by hyperthyroidism secondary to increased bone turnover. Therefore, a PTH level would more likely lead to the correct diagnosis. CT scanning of the neck (choice D) is very sensitive for parathyroid disease but it is not meant to be used as a screening test for hyperparathyroidism. Rather, the diagnosis is made by checking serum calcium and PTH levels. Multiple myeloma is a common disease and can cause hypercalcemia as well. A serum protein electrophoresis (choice E) is helpful in making this diagnosis by demonstrating a monoclonal spike in the beta or gamma globulin region. Our patient lacks anemia, renal disease, or significant back pain which makes multiple myeloma less likely.
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