الموضوع: Emergency Room
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قديم 03-07-2008, 09:29 AM
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افتراضي

Tense ascitis ( TTT)
1-Rest in bed.2-Salt restriction ( salt free diet )3-Diuretics:

a) Start with Spironolactone (Aldactone) 100 mg قرص بعد الغداء

And increase gradually up to 4 tablets \day Value : K sparing diuretic, Aldosterone antagonist.

b) Lasix 40 mg daily up to 4 tablets ( 160 mg\d)

N.B.: Diuretics esp. Lasix stopped if there is hyopkalemia or precoma

4-Follow up pt. with fluid chart

(body wtàtarget: decrease B.wt by 1\2 kg \day.)

5-If resistant à Tapping or paracentesis should be done if tense ascitis cause significant discomfort or resp. distress ( Therapeutic purpose of tapping )



6-Tapping:


a-Exclude encephalopathy. b-Palpation of abdomen to avoid injury to any organ during tapping . c-Sterilization of (Macburny's point) or mid way bet. Costal margin & ASIS( most dependant area) ***Sterilization is done in circular manner from in into out by betadine then alcohol. d-introduce canula + IV line.
- Replacement with albumin if tapping > 3L (one bottle contain 10gm)

- Stop if : hypotension , bleeding of tapping ,, disturbed conc. Level.



N.B.:-
  • Diagnostic purpose of tapping : if suspicion of malignant ascitis or SBP or new onset ascitis.
  • Fluid obtained from tapping : 3 samples for : culture & sensitivity, chemistry, pathological exam.
  • Indication of Albumin in CLD Pt.:
- Tapping > 3 L of ascitis fluid. - Infection - Surgery - SBP - Hepatorenal $





SBP ( spontinous bacterial peritonitis ):



Infectious complication of portal HTN related ascitis in absence of cause for peritonitis . most commen org : E-coli….



C\P : Pt with CLD with [ marked deterioration precipitate hepaticencephalopathy],, [ fever, abd.pain , tenderness ] ,, [ silent]



D.D : leucocytosis may be present

Diagnostic paracentesisàcell count [WBC >500\ m3\HPF with out sympt.,,PNL >250 \m3\HPF with symptoms ]



TTT: - Antipyretic.

- Antibioticà3rd generation cephalosporin E.g. : cefotaxime "claforan" 1 gm \ 8 h for 5 days unless there is renal failure ((dose adjustment)) - Anticoma measures ( previousely mentioned ) - Albumin.



Hepatic encephalopathy :-



It's neuropsychiatric complex in pts with acute or chronic LCF or portosystemic shunting(i.e.: disorderd conciousness, abnormal behavior…)

Ask about ppt factors in Ch. Liver disease pts :

-Diuretics

-
High dietary prot.

-
Haematemsis, melena

-
Fever (infection)

-
SBP

-
Severe vomiting or diarrhea, excess tapping of ascitis.

-
Hepatotoxicity ( alcohol ,drugs e.g. : sedative, opiod…)



Management :

1-Vital data ((fever. Haematemsis ))2-Canula à sample for ****bolic profile. ( Na, K, Creat, RBS)3-Ryle &wash to exclude haematemsis.4-Chest x ray à ( chest infection. . Rt sided P.effustion.5-ECG





TTT:

1- To avoid prot. In diet. 2- Eradicate bact. Flora by: - Neomycin 500 mg 2*4*5

Flagyl 250 mg 1*3*7 - Lactulose 30 ml \8 h. (osmotic purgative ) - Enema \4h

3- Hepamerz"L-Arnithine – L-aspanate (2 amp +200cc glucose 10% \12 h.)

à if creat > 3

4-Aminolesan 500ml\12h (AA infusion

5-TTT of the cause :

E.g. : Haematemsis àDicynon ,konakion, cyclokapron ,zantac…….

Infectionà TTT
SBPà Antipyretic, Antibiotic, Anticoma, Albumin……



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