RESUMO
Idiopathic retroperitoneal fibrosis is a rare fibro-inflammatory disease of varied etiology which usually originates around aorta and spreads caudally along Iliac vessels into adjacent retroperitoneum causing ureteral obstruction as the most frequent complication.A 53-year-old male patient presented with complaint of mild pain in both the legs off and on. On investigating further, we found that he had been struggling with intermittent relapses every 3-4 years for last 20 years since he was first diagnosed with Idiopathic Retroperitoneal Fibrosis. He was 33-year-old when he first developed the symptoms of anuria for 48 hours and was diagnosed with Idiopathic retroperitoneal fibrosis. This was followed by atrophy of left kidney and hypertension 6 years later, then hypothyroidism after another 3years and finally involvement of Inferior Vena Cava and acute Deep Vein Thrombosis of lower limbs after another 3-4 years. His deep vein thrombosis was well managed in time. He was put on glucocorticoids everytime he had a relapse and a complication.We did a review of literature to understand recent advances about its pathogenesis, diagnosis, investigations and management. We searched in PubMed using terms like retroperitoneal fibrosis alone and in combination with related terms such as Inferior Vena Cava thrombosis, Deep Vein Thrombosis, Tamoxifen, Methotrexate. This case is unique as it is very rare to find acute Deep Vein Thrombosis in Idiopathic retroperitoneal fibrosis without development of any collaterals when Inferior Vena Cava lumen is compromised to almost complete obstruction.After a follow up of 20 years patient is doing well in terms of physical activity and psychological wellbeing with anti-hypertensives, thyroxine and anti-coagulants. Is the disease-free interval actually free of the disease or it just subsided with immunosuppressants to become active after some time?
La fibrosis retroperitoneal idiopática es una enfermedad fibroinflamatoria rara, de etiología variada que generalmente se origina alrededor de la aorta y se propaga caudalmente a lo largo de los vasos ilíacos en retroperitoneo adyacente causando obstrucción ureteral como la complicación más frecuente.Reportamos el caso de un paciente varón de 53 años que se presentó con un dolor leve en ambas piernas. Al investigar más a fondo, descubrimos que había estado luchando con recaídas intermitentes cada 3-4 años durante los últimos 20 años desde que se le diagnosticó por primera vez fibrosis retroperitoneal idiopática. Tenía 33 años cuando desarrolló por primera vez los síntomas de anuria durante 48 horas y se le diagnosticó fibrosis retroperitoneal idiopática. Esto fue seguido por atrofia del riñón izquierdo e hipertensión 6 años después, luego hipotiroidismo después de otros 3 años y finalmente afectación de la vena cava inferior y trombosis venosa profunda aguda de las extremidades inferiores después de otros 3-4 años. Su trombosis venosa profunda se controló bien a tiempo. Le recetaron glucocorticoides cada vez que tenía una recaída y una complicación.Hicimos una revisión de la literatura para comprender los avances recientes sobre su patogenia, diagnóstico, investigaciones y manejo. Se realizaron búsquedas en PubMed utilizando términos como fibrosis retroperitoneal sola y en combinación con términos relacionados como trombosis de la vena cava inferior, trombosis venosa profunda, tamoxifeno, metotrexato. Este caso es único, ya que es muy raro encontrar trombosis venosa profunda aguda en fibrosis retroperitoneal idiopática sin desarrollo de colaterales cuando la luz de la vena cava inferior está comprometida hasta una obstrucción casi completa.Después de un seguimiento de 20 años, el paciente se encuentra bien en términos de actividad física y bienestar psicológico con antihipertensivos, tiroxina y anticoagulantes. ¿El intervalo libre de enfermedad está realmente libre de la enfermedad o simplemente disminuyó con inmunosupresores para activarse después de algún tiempo?
Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Fibrose Retroperitoneal/complicações , Fibrose Retroperitoneal/diagnóstico , Fibrose Retroperitoneal/terapia , Recidiva , Fatores de Tempo , Tomografia Computadorizada por Raios X , Diagnóstico Diferencial , Hipotireoidismo , Imunossupressores/uso terapêuticoRESUMO
Aim: The hemodynamic effects of propofol-fentanyl and isoflurane-fentanyl anesthesia during surgery were compared in 100 patients undergoing coronary artery bypass grafting (CABG) and valvular surgeries. Material and Methods: Patients were divided into two groups randomly. Group PF (n=50) were induced with Fentanyl, Midazolam, Vecuronium and Propofol infusion. While Group IF (n=50) were induced with Fentanyl, Midazolam, Vecuronium and Isoflurane (0-2%) as per the standard doses. Hemodynamic measurements were made before induction of anesthesia and at various times throughout the surgery. Observation and Results: Significant decreases in mean arterial pressure MAP, left ventricular stroke work index (LVSWI), and stroke volume index (SVI) occurred after 15 minutes of propofol anesthesia. With isoflurane MAP was well maintained with reductions in LVSWI and SVI. Isoflurane was, however, associated with a slight increase in heart rate (HR), whereas no significant change in HR in patients receiving propofol. With both techniques there was no significant change in systemic vascular resistance index. Isoflurane prevents myocardial damage and thus it is cardio protective by developing ischemic preconditioning phenomenon. Conclusion: The study suggests that propofol-fentanyl anesthesia is an acceptable technique but Isoflurane- fentanyl is still preferred due to less hemodynamic instability and greater myocardial protection in cardiac surgeries.
RESUMO
Background: Accurate management of post operative pain is quite impossible with single drug therapy approach. For this, our aim was to combine use of tapentadol tablet orally along with thoracic epidural in comparison with intravenous combined use of tramadol, paracetamol and diclofenac for postoperative analgesia in case CABG patients. Methods: 60 patients of CABG (Coronary Artery Bypass Surgery) randomly and equally divided into two groups. Group TTE (Tab. Tapentadol -Thoracic Epidural, n=30) were given oral Tablet Tapentadol through NG (Nasogastric) tube at the time of shifting the patient from Operation Theatre to postoperative ward along with Tramadol through Thoracic epidural catheter. In Group TPD (Tramadol -Paracetamol -Diclofenac, n=30) were given Inj. Tramadol, Inj. Paracetamol IV at time of shifting of patient. If pain score is too high (>4) then additional analgesia were given with Diclofenac only if preoperative renal and hepatic profile were normal. Patients were monitored for duration of rescue analgesia, total no. of doses of analgesics in first 72 hours, total consumption of analgesics and response to physiotherapy. Results: Duration of need of rescue analgesia was significantly longer in TTE group (p<0.05) while total no. of rescue doses were significantly more in group TPD (p<0.001). We also observed that patients of TTE group were recovered earlier, response to chest physiotherapy was significantly better and thus reduces their total length of ICU stay (p<0.05). Conclusions: Our study concludes that Tapentadol with Thoracic epidural is very much effective as a multimodal analgesia approach in controlling acute postoperative pain after CABG. Tapentadol is quite a newer drug so its usefulness for other patients and different surgeries is still to be debated.
RESUMO
Sternal osteomyelitis secondary to penetrating trauma is an uncommon entity and only few cases have been reported. We report a case of sternal osteomyelitis in a patient with sickle-cell anaemia with a unique past history of arrow-head injury who presented with signs and symptoms of sternal infection. Imaging studies suggested osteomyelitis and the patient underwent sternal debridement, with a successful outcome.