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Colesterolul – adevaratul ucigas din umbra

Colesterolul – adevaratul ucigas din umbra. Maura Gabriela Felea SRMI – august 2011. Internare zi – Cl Endocrinologica. Analize : TSH = 0.5 uUI/ml, FT4 = 1,4 ng/dl ABC = frotiu de tip benign

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Colesterolul – adevaratul ucigas din umbra

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  1. Colesterolul – adevaratul ucigas din umbra Maura Gabriela Felea SRMI – august 2011

  2. Internare zi – Cl Endocrinologica • Analize: TSH = 0.5 uUI/ml, FT4 = 1,4 ng/dl ABC = frotiu de tip benign • Eco tiroida: VT = 161,5 ml. LTD ocupat de noduli 7/9,2/4,7 neomogen, cu fante vasculare, halou transsonic • Concluzii : dimensiunile nodulului tiroidian impun suprimarea chirurgicala (ORESGOR) • Rec: • Ecoplan 20 mg seara → lipidograma dupa 2-3 luni; • regim alimentar hipoglucidic

  3. TSH < 0,6 mU/l sau > 4 mU/l palpare Scintigrafie in caz de hipertiroidie Nodul intr-o GMN? Nodul solitar Tratament in functie de etiologie (Basedow, nodul autonom, tiroidita) US Biopsie Benign (macrofolicular) Suspect (microfolicular) Cancer papilar operatie urmarire

  4. Histologia nodulilor tiroidieni • Leziuni benigne (90-95%) • Nodul coloid • Adenom • Chist • Hashimoto, de Quervain, postinfectie • Leziuni maligne (5-10%) • Cancer (papilar, folicular, medular, anaplazic) • Limfom (rar) • Metastaze (rar)

  5. 15.02

  6. Internare Cl. Chirurgie 12.03-9.04 • ♂ 54 ani;U - IS; scoala profesionala • MI • Semne de edem reg. cervicala ant. • Disfonie • APP: HTA gr. II risc moderat, FA cr. • Comportament: neaga consum alcool, cafea, tutun • T=182, G=108 → IMC=32,6 kg/m² • TA 160/70 mmHg, FC=95/min • Abdomen ↑ vol. (obezitatii); • Ex local: reg cervicala ant. cu noduli mobili cu deglutitia si pe planurile superficiale, nedurerosi

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  8. Ex. ORL • 8.03 – Rinita acuta (lavaj nazal, vit A). Laringoscopie indirecta: acelasi aspect de laringita cronica, glota libera, discret edem posterior • 13.03 – Endolaringe si hipofaringe – aspect normal si mobilitate normala

  9. Se intervine: • TIROIDECTOMIE TOTALA; drenaj 1 tub

  10. Ex anatomo-patologic • Macroscopic: • LTD = 8,5/6,5/4,5 cm cu un nodul de 6,5-5/cm alb-galbui, cu zone de hemoragie • LTS = 3,8/2,2/0,5 cm • Microscopic: • Nodul adenomatos medio si macrofolicular, cu zone hiperfunctionale si sclerohialinoza interstitiala; capsula integra in sectiunile examinate • Adenom tiroidian mediofolicular, + zone hiperfunctionale, + important edem si sclerohialinoza cicatriceala in interstitiu. • Arii cu degenerare mucoida a interstitiului si zone de hemoragie in curs de organizare conjunctiva • Tesut tiroidian adiacent cu aspect anizofolicular, hipofunctional • Gusa coloida anizofoliculara cu edem in interstitiu.

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  12. Gusa sau Nodulul tiroidian – Indicatii operatorii • Simptome (compresie traheala, esofagiana, discomfort cervical) • Crestere continua in volum • Chist recurent/Nodul eutiroidian recidivant > 4 cm in ciuda aspiratiilor • Jena estetica • Hipertiroidie (optiunea pacientului) • Nodul malign sau suspect de neoplazie la citopunctie • Nodul rece inaccesibil la citopunctie (gusa plonjanta)

  13. Chirurgia tiroidei • 14.934 pacienti supusi unei urmariri de 5 ani • 3130 (20.9%): lobectomie totala (LT), • 9599 (64.3%): tiroidectomie totala (TT), • 1448 (9.7%): tiroidectomie subtotala cu un rest monolateral (MRST), • 757 (5.1%) tiroidectomie subtotala cu un rest bilateral (BRST) Complications of Thyroid Surgery: Analysis of a Multicentric Study on 14,934 Patients Operated on in Italy over 5 Years World Journal of Surgery, Volume 28, Number 3, 271-276, DOI: 10.1007/s00268-003-6903-1 http://www.springerlink.com/content/dag57yvp21myj84e/

  14. Complicatiile asociate chirurgiei tiroidei • hipoparatiroidism persistent: 1.7% (hPTH dupa TT = Co imp) • hipoparatiroidism temporar: 8.3% • paralizie permanenta a nervului laringeu recurent (NLR): 1.0% (impact important in viata sociala) • paralizie tranzitorie a NLR: 2.0% • diplegie in 0.4% • lezare nerv laringeal superior: 3.7% • disfagie: 1.4% • hemoragie: 1.2% • infectia plagii: 0.3% • hipocalcemie

  15. Comentarii • In April 2006 at the annual meeting of the American Association of Clinical Endocrinologists (AACE), Roberto Valcavi, MD, Director of the Thyroid Disease Center in Reggio Emilia, Italy : • Chirurgia cu laser – tratamentul de viitor al nodulilor benigni (30’; sedare usoara: Valium) • In multe studii, tratamentul de substitutie cu levothyroxine (trat. traditional): ineficace • Un alt abord comun, extirparea chirurgicala partiala/ totala poate prezenta complicatii: hipocalcemia sau lezarea corzilor vocale. • Ambele chirurgii: potential de lezare nervoasa.

  16. La 48h postop.: • Durere toracica importanta cu iradiere dorsala • Dispnee severa cu cianoza in ½ sup corp ! Se afla sub tratament cu Clexane ↓

  17. Eco cord de urgenta 18.03 • Tahicardie • HVS (PPVS=SIV= 15 mm) • VD 49 mm, VCI cu colaps inspirator ↓, regurg. tricuspidiana moderata • N-izarea VD, FE 60%, V. femurale comune si V. poplitee permeabile • Lab • D-dimeri ≥ 3 g/ml FEU (2 FEU = 1 D-dimeri) • Testul monomerilor de fibrina +++ • Rgr torace • ↓ transparentei pulm dr (pleurezie in cantit ↓) • Largire mediastin sup bilat (desen pulm accentuat de aspect vascular - decubit)

  18. transfer ATI : • IOT • Suport inotrop pozitiv si vasopresor Stare generala agravata (stop cardiocirculator 30’) • trombolitic

  19. IOT + VM • Pacient febril + BiPAP • raspuns bun sub trombolitic (cvasiN PCO2 si PO2) • Sangerare posttromboliza in loja tiroidiana • Diureza: 100 → 50 ml/h • TAS 124-150 mmHg, AV 92/min

  20. 25.03 – episod matinal de confuzie si sangerare in loja (hematom cervical in crestere) → reinterventie • Hemostaza in situ, drenaj cu lama • Ligatura art. tiroidiene sup. dr. • AB pt IU cu Enterobacter aerogenes • AB contra Acinetobacter specie din secretia traheala • Transfuzii repetate de sange integral

  21. D 1515 ml → HD → 750 ml • Dezvolta Insuficienta hepatorenala acuta • Uree 280 mg/dl • Creatinina 10 mg/dl • TGP > 800 UI • HD zilnica • Ameliorare treptata a f(x) renale si hepatice • Reluare treptata a diurezei • N-izare uree, creatinina

  22. Tendinta la ↑ TA (170-190 mmHg) • Raluri ronflante hemitorace drept → bilateral • HD • Subfebril • SO2: 90-98% (O2 pe canula nazala)

  23. AB masiv • Transfuzii de sange integral • Reia diureza • Stare gen. lent fav. • Intrerupere trat inotrop+ si vasopresor • La 5 zile: • hg loja cervicala ant (Hb 9 → 8 g/dl) • Heparina pe injectomat • Reinterventie • hg difuza → hemostaza cu fire separate • Suprimare fire in 7 zile, lama de dren la 10 zile ! Sdr confuzional cu somnolenta

  24. Ex neurologic – 31.03 • Pacient cooperant, orientat • Cecitate corticala. Apraxie mana stg. Pareza nv. VI dr.

  25. Simptomele sunt explicate de: • Infarctul occipital dr • Edemul cerebral aparute in contextul stopului cardio-circulator cu hipoTA • Transformarea hemoragica = secundara trombolizei si se va resorbi in timp • Tratament • Manitol + DEXA • Stop Cerebrolysin → Piracetam 3 g/zi • Sintrom 2 mg (INR = 2-3) • Tanakan 1 ml sol (1 tb) x3/zi • Sortis 20 mg/zi

  26. IRM cranio-cerebral nativ – 7.04 • Emisfer drept : • Edem F-T-P-O cu infarct intins T-P-O dr transformat hemoragic cortico-subcortical (F stg?) • Edem O cu infarct occipital posibil transformat hemoragic (discret/ central dr)

  27. Dg la externare • Gusa polinodulara cu fenomene de compresiune • Embolie pulmonara masiva • Stop cardiocirculator resuscitat • Hemoragie secundara • Soc hipovolemic • Anemie secundara • IRA • Insuficienta hepatica • HTA grI • Obezitate grI • Hemoragie intracerebrala. Edem cerebral • Cecitate cortcala

  28. Evolutie • 12-14-15-16.03: TA = 130/70 • Oprire heparina → sintrom • Evolutie lent favorabila • Externare in ziua a 29-a de la internare

  29. Recomandari • Sintrom • Regim igieno-dietetic • Dispensarizare repetata in Clinica de Recuperare Neurologica • Reevaluare si tratament adjuvant in Clinica de Endocrinologie • Control la 1 luna interval

  30. Reevaluare periodica – 11.04.2008

  31. Reevaluare periodica – 04.02.2010

  32. CHA2DS2-VASc ²In antecedente: Infarct miocardic, boala arteriala periferica, ateromatoza aortica

  33. Va mulţumesc!

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