surgical diagnosis
রবিবার, ২০ নভেম্বর, ২০১১
ACID BASE DISORDERS
Importance of Ph
1.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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