রবিবার, ২০ নভেম্বর, ২০১১
ACID BASE DISORDERS
Importance of Ph1.To keep the enzymatic activity
2.To maintain the active structural and functional conformation of biomolecules
3.To maintain the cellular viability
Na-K+ pump failure
sickle cell syndrome
acidaemia
digitalis toxicity
Source of acid Both exo & endogenous
Acid amount source disposal amount reserve
Volatile 15mole/day lung 15mole/day 30-40
CO2
Non volatile 70mmol/day kidney 70mmol/day 500
H2SO4 protein
H3PO4 PL/P.prot
HCL
LA
KA
| Respiratory acidosis Ventilatory failure pneumonia bronchitis Asthma emphysema Depressed nervous Morphine poisoning | Respiratory alkalosis Hyperventilation voluntary hysteric CNS disease affecting respiratory center Salicylate poisoning Hepatic coma |
| Metabolic acidosis Normal anion gap (HYPERCHLOREMIC) (git HCO3 loss) diarrhoea fistulae uretero sigmoidostomy renal HCO3 loss RTA acetazolamide ↑HCL production NH4cl ingestion Increased anion gap (NORMOCHLOREMIC) DKA LA RF( acute + chronic) salicylate poisoning | METABOLIC ALKALOSIS Loss of acid vomiting aspiration Excess alkali adminstration (citrate,acetate,lactate,gluconate,HCO3-) Diuretic ECF vol depletion(renal Na+ reab in exchange of H+) Aldosteronism(primary/2nd ary)Cushing’s syndrome Post hypercapnic alkalosis |
Total buffer base = 48meq/L HCO3- 25-28meq/L
Hb - 15meq/L
prot-
HPO4- -
Standard serum HCO3- conc
body temp 37°c
Pco2 40mmHg
Hb normal concentration
saturated with O2
SIRS PATHOPHYSIOLOGY AND TREATMENT
COMPOUNDING INSULT
C/F Rx
1.simple resuscitation
fluid
High flow O2(face mask)
2.Global approach
inotropes/vasoactives
(dobu,enoxamine,piroximone,milrinone,amrinone)
3.Regional approach
regional perfusion measured by
renal output renoprotectives
adult mannitol ml/bw
child frusemide
infant renal dose dopa
(increase output but cant increase perfusion
rather increase CO)
Gut luminal Ph/PCo2/acidosis
Fluid+blood+inotrop(dobu+dopex)
4.avoidig nosocomial infection
Rx nosocomial pneumonia(spillage from UGIT)
Avoid H2 blocker
Use sucralfate
SDD()-destruct pathogen bt maintain commensal anaerobe
5.Rx enotoxaemia
anti endoxin antibody
active immunization before major surgery
bacterocidal/permeability protein
endotoxin neutralizing protein
dextran-polymixin-B conjugate
SIRS
responsible agents Rx
1.cytokines:mobilization,localization and activation I . Ab to TNF-alpha, IL1
of leukocytes by TNF-alpha, IL1 II . low dose dexamethason
(inhibit synth,secretion
high dose—failure)
2.Arachidonic acid metabolites
(play role in MODS) Ibuprofen
protective-PGE2 Indomethacin
Cox inhibitors
deleterious-(Lt, Tx)
3.Degranulating Neutrophils
release free radicles super oxide.dismutase
microvascular injury Allopurinol
vit-C
4.contact,coagulation,compliment activator
(DIC due to imbalance bet pro & anti coagulants) Anti Thrombin III
C1 esterase
5.Endogenous Anti inflammatory agents Anti IL-1, Anti TNF-alpha
regulating IL1,TNF-alpha IL-10(macrophage deactivator)
6.NO
as vasodilator—septic shock block by NMMA(Ng-monomethyl
-arginine)
( restore vascular resp to catecholamine )
modify neutro-plat interaction---MODS(by
microvas occlution)
ARDS-admin NO
(it increases O2 supply by pulm vasodilation
without any syst effect-decreases PA pressure)
Breast Tumor
TNM/MANCHESTER/IUAC SYSTEM
Tis-carcinoma in situ
To-not palpable
T1-<2cm
T2-2-5cm
T3->5cm
T4-a.chest wall (fixed to chest wall)
b. skin involvement(oedema,lymphocytic infiltration,ulceration,satellite node
c.(a+b)
No-no nodal
N1-ipsi mobile axillary LN
N2-ipsi fixed
N3-Ipsi internal mammary LN/
clavicular node/
arm oedema
Mo-no met
N1-distant met
Staging(IUAC)
l stageI=<2cm
l stageII=<2cm +ipsi ax LN(not fixed LN/<N2)
2-5cm±ipsi ax LN(not fixed LN/<N2)
l stageIII=chest involvement + any stage of LN
any size + fixed LN
l stageIV=any size+any LN+ dist.met
l Stage TNM description 5yearsurvival RX
l I TINoMo early 84%
l II T1N1Mo/T2No-1Mo early 71%
l III any TN2-3Mo/T3anyNM0 locally adv 48%
l IV any T,anyN,M1 metastatic 18%
Grading(Bloom & Richardson grading system)
l I=well differentiated
l II=moderately diff
l III=poorly diff
NPI scoring(Nottingham Prognostic Indicator)
l (.2xtumor size)+grade+ LN status
1=no nodal
2=1-3 nodes
3=4/>4nodes
High score =bad prognosis(80%survival for 15yrs)
low score =good prognosis(13%survival for 15yrs)
NPI prognosis 5yr survival
2-2.4 excellent 93%
2.4-3.4 good 85%
3.4-5.4 moderate 70%
>5.4 poor 50%
good prog bad prog
ER(+ve) lymphovascular invasion
HER-2(+ve)
PROGNOSIS
l Grade
l Hormone receptor status
l Tumor proliferation
s-phase fraction
thymidine lebel index
growth factor
oncogene/oncogene product
MASTECTOMY
l >4cm
l Multifocal
l Central
l Locally advanced
l Metastatic
l Inflammatory ca
l Breast conserving surgery
l Level 2/3 axillary clearance
l POST MASTECTOMY
RADIOTHERAPY
GradeIII,multifocal,near to skin/muscle
≥4cm
>3axillary LN
Lymphovascular invasion
RELAPSE AFTER RADIOTHERAPY
l <35years
l Multifocal
l Insitu(@margin of excision)
HORMONAL THERAPY
l Tamoxifen(SERN)
l 1st line Rx for ER(+ve) & PR(+ve)
l pre & post meno
l Arimidex(aromatase inhibitor) blocks peripheral conversion of androgen to oestrogen
l ER(+ve)post meno
l ER(+ve)post meno intollerant to Tamoxifen
l ER(+ve)post meno with thrombotic disorder
l Zoladex (GOSERELIN)
l ER(+ve) premeno
l OVARIAN ABLATION
l ER(+ve)
CHEMOTHERAPY
l Young ER(-ve) premeno
l gradeIII
l large
l lymphovascular invasion
l LN(+ve)
l young
l visceral involvement
FEC/CMF 2cyles 3wkly
30%reduction of recurrence for 10-15years
To shrink the size prior mastectomy
Adjuvant therapy (given after ot-CHOR)
l LN (+ve)
l Poor prognosis LN(-ve) premeno
NEOADJUVANT(prior Ot -HC)
l Young woman
l Young woman with High grade
l >3cm
l Down grade the tumor to do conserving surgery(to avoid mastectomy)
l Inflammatory ca
l If LN +ve= Radio/Chemo
Then look for ER
ER(+ve)=Hormonal
premeno -Zoladex
postmeno -Arimidex (musculoskletal prob,path#)
pre/post -Tamoxifen (most effective bt
more adverse effects –thrombotic disorder)
20mg/day for 2-5 years
PR(+ve) -Tamoxifen
ER(-ve) = Chemotherapy
l Tamoxifen: for postmeno regardless of LN status
prevent controlateral recurrence
DISEASE AGE SIZE POSITION FINDINGS RX
Juvenile adenoma <15years red mammoplasty
fibroadenoma 15-40years <1-<5cm unilat <1-2cm reassurance
>3cm enucleation
Giant F/A >5cm excision
Phylloid 40-50years >3cm(rapid growth) excision
Duct papilloma 35-50years not>1cm sing/multiple bloody/watery dc microdocotomy
ǿ2cm of nipple, /hadfield
single duct
us-dilated duct/papilloma
cyto-epith/Rbc
Periductal mastitis 35years yellow dc,smoker
Lipoma radioluscent
Inverted nipple tripple assessment
cytology duct division/excision
Early(StageI & stageII) :WART(UK)with 1cm healthy margin
QART(italy)
Locally advanced:MART
toileting mastectomy±radio/hormonal ±chemo
(but no axillary clearance)
Distant: MART
DCIS:WART(±)
LCIS:follow up mammography±radio±axillary clearance
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