Medical Treatment of Cholangitis
The
cholangitis is a therapeutic emergency, ask her diagnosis implies in
most cases the rapid achievement of a surgical procedure to remove the
obstacle located on the VBP, but the recent concept of cholangitis
reversed this notion of the
importance of near-total surgery and provides great value to the
medical component of care, by which its effectiveness can be attributed
to a large surgical success rate.This
medical treatment should in no case delay the surgery for which the
appropriate timing will be the result of collaboration between
physicians, surgeons and intensivists.The aim of this collaboration is to provide appropriate therapy, minimally invasive. The management of the patient is best performed by specialists with experience in various procedures.This
collaboration is also illustrated in the realization of combining
different approaches and procedures in the management of failures and
complications of each method.Interventional radiology procedures are potentially long bladder, painful and iterative. For patient comfort and indirectly of the operator, an anesthetic management must allow for sedation and analgesia.Depending
on the complexity and pain of the gesture, the anesthetic management
ranges from simple oral premedication with a sedative (hydroxyzine:
Atarax ®), general anesthesia with intubation, through the combination
of benzodiazepine and opioid diazanalgésie .A management by resuscitative measures may be indicated before and after the procedure. A
patient with obstructive jaundice develops more or less long term
intercurrent disorders, whether kidney problems, coagulation,
nutritional, infectious and hydro electrolyte.The management of these fragile patients by intensive care to a large extent determines the short-term prognosis.Goal of treatment
* Fight against infection.
* Treatment of metabolic disturbances.
* Treatment of shock.
* Treatment of renal failure.Fight against infectionIndicated by the antibiotic in all cases, the choice should be based on theoretical data of the susceptibility, but in fact the antibiotic should be implemented before or known the results of blood cultures using antibiotics to eliminate bladder, active against gram-negative bacilli (usually found in cholangitis) and administered parenting [2].The choice of these antibiotics may be modified secondarily according to the nature of the organism found in blood culture and susceptibility data.Antibiotic therapy should cover all the intestinal bacteria, including common germs: E coli (39%), Klebsiella (54%), Enterobacter (34%), Enterococci (34%), Streptococci D.
Tableau : Antibiothérapie en fonction du germe :
It is best if it fails to change the antibiotic rather than increasing the dose thoughtlessly.
Gentamicin has a significant nephrotoxicity, which should be assessed by the occurrence of renal failure.
Treatment of metabolic disturbances
It seeks a balanced diet and hydroelectric satisfactory. Prevention or correction of dehydration is provided by a supply of water and electrolytes in amounts appropriate to the data of clinical and biological.
Maintaining proper kidney function based on the correction of circulatory abnormalities and hydro electrolyte, the use of renal replacement therapy is sometimes necessary.
Treatment of shockThe sequence of events clearly indicates that hemodynamic hypovolemia plays a fundamental role in the onset of septic shock, so the first treatment goal should be to restore blood volume and the increase in this one as much as is necessary, but always under constant surveillance of the PVC that should remain below 10 cm of water because the risk of pulmonary edema is real [7].This treatment is based primarily on volume replacement using:
* Fresh frozen plasma + + +
* Sang HK especially if <30% (RBC)
* Albumin: Fight against hypoalbuminemia secondary to septic shock. Maintaining a normal colloid osmotic pressure to reduce the risk of PAO.
* Colloids: Plasmagel, Dextran
* Crystalloids: hypertonic saline in cases of a hydroelectric disorders and acid-baseIf signs of shock persist, and when the central venous pressure (PVC) rises above 15 cm of water demonstrates incompetence myocardial must use the cardio and vasoactive drugs:- Dopamine (2-5mg/kg/mn):
* Increases intrinsic myocardial contractility and heart rate.
* Vasodilation in the kidneys and splanchnic.
* Vasoconstriction moderate muscle and skin vessels.- Dobutamine:
* Predominantly positive inotropic action
* Little effect tachycardisant
* No renal dilatationTreatment of renal failureDefinition: Renal failure is [31]:
* Linked to decreased renal perfusion without cellular injury.
* The extension in time predisposes to the occurrence of acute tubular necrosis.
* Is rapidly reversible when the underlying cause is corrected.
* The most common form of acute renal failure.
* Frequent postoperative contexts (hypovolemia, drugs) and in the elderly because of their predisposition to hypovolemia and the presence of atherosclerotic renal disease.Regardless of any treatment of the case, the therapy of acute renal failure is inconceivable that a specialized, it focuses on the treatment of complications:Extracellular hyperhydration:Especially complicated forms oligo-anuric:* Diet: fluid restriction <500 ml / day, sodium and 4 g / d;* Loop diuretic: Furosemide in high doses;* On failure and persistent anuria in 24 hours, indicative of renal replacement therapy with ultrafiltration.Metabolic acidosis:- To correct if decompensated or if clinical impact.- Need to correct hypocalcemia in advance because of increased risk.In the absence of congestive heart failure or pulmonary edema:* Infusion of sodium bicarbonate.- If it is severe (bicarbonate = 10 mmol / l), indicative of renal replacement therapy by hemodialysis.Fight against hyperkalemia (KAYEXALATE ®).Correction of hypocalcemia and hyperphosphatemia:- Administration of calcium carbonate.- These disorders are effectively treated in an institution of renal replacement therapy.Indications for renal replacement therapy?In emergencies, when the prognosis is at stakeIn contexts of severe ARI, anuric, with the following events:
* Hyperhydratation extracellular with pulmonary edema, severe hypertension.
* Hyperkalemia symptoms (clinically or electrical anomalies).
* Severe metabolic acidosis (bicarbonate = 10 mmol / l, pH <7.2).
* Greater nitrogen retention.Presence of new-onset neuropsychiatric disorders:* Hemodialysis is the method used in emergency situations. The vascular access is obtained after implantation of deep venous catheters: internal jugular or femoral;* The first session should be brief (02 hours) to avoid severe neurological disorders associated with too rapid correction of electrolyte disturbances.
* Fight against infection.
* Treatment of metabolic disturbances.
* Treatment of shock.
* Treatment of renal failure.Fight against infectionIndicated by the antibiotic in all cases, the choice should be based on theoretical data of the susceptibility, but in fact the antibiotic should be implemented before or known the results of blood cultures using antibiotics to eliminate bladder, active against gram-negative bacilli (usually found in cholangitis) and administered parenting [2].The choice of these antibiotics may be modified secondarily according to the nature of the organism found in blood culture and susceptibility data.Antibiotic therapy should cover all the intestinal bacteria, including common germs: E coli (39%), Klebsiella (54%), Enterobacter (34%), Enterococci (34%), Streptococci D.
Tableau : Antibiothérapie en fonction du germe :
Nom de l’ATB
|
AMPICILLINE -- Empêche la synthèse de la paroi cellulaire de la bactérie durant sa phase
de multiplication active => Activité bactéricide. Doit être combiné avec d’autres drogues. |
Dose adulte
|
2 g IV q6h
|
Dose enfant
|
50 mg/kg IV q6h
|
Contre-indications
|
Hypersensibilité, Allergie
|
Interactions
|
PROBENECIDEE augmente les effets de l’AMPICILLINE; allopurinol diminue ses effets.
|
Précautions
|
Ajuster la dose en cas d’insuffisance rénale; Surveiller les réactions d’allergie.
|
Nom de l’ATB
|
PIPERACILLINE – Inhibe la biosynthèse des mucopeptides de la paroi, effet durable durant la phase
de multiplication active, activité anti-pseudomonale. |
Dose adulte
|
4 g IV q6h
|
Dose enfant
|
N’a pas été établie
|
Contre-indications
|
Hypersensibilité, Allergie
|
Interactions
|
Tétracyclines diminuent son effet; PROBENECIDE peut majorer ses effets; coadministration avec aminoglycosides
a des effets synergétiques |
Nom de l’ATB
|
METRONIDAZOLE (FLAGYL®) -- actif contre les germes anaérobiques et les protozoaires. Usuellement employé en association
avec d’autres agents anti- microbiens. |
Dose adulte
|
1 g IV dose de charge, suivie par 500 mg IV q6h ou 1 g IV q12h
|
Dose enfant
|
7.5-15 mg/kg/j IV en 02 fois
|
Contre-indications
|
Hypersensibilité, Allergie
|
Interactions
|
Peut augmenter la toxicité des anticoagulants, Lithium, and PHENYTOÏNE; cimétidine peut
augmenter sa toxicité. |
Précautions
|
Ajuster la dose en cas de pathologie hépatique; surveiller la survenue de neuropathies périphériques
|
Nom de l’ATB
|
GENTAMYCINE (GENTACIDINE, GARAMYCINE) – Antibiotique Aminoglycoside pour couverture BGN. Utilisé en
association avec un anti gram positif et un agent actif contre les anaérobies. Posologie ajustée en fonction de la clairance de la créatinine. |
Dose adulte
|
3-5 mg/kg/j IV en 3 fois
|
Dose enfant
|
5-7 mg/kg/j IV en 3 fois
|
Contre-indications
|
Hypersensibilité, insuffisance rénale
|
Interactions
|
Co-administration avec d’autres aminoglycosides, Céphalosporines, Pénicillines, peut augmenter
la nephrotoxicité; un TRT prolongé par les aminoglycosides pourrait entrainer une dépression respiratoire. Co-administration avec les Diurétiques peut engendrer une toxicité auditive ce qui provoquerait une possible perte auditive irréversible. |
Grossesse
|
Contre indiqué
|
Précautions
|
Surveiller le dosage de la GENTAMYCINE pour prévenir l’ototoxicité; attention aux patients
avec décompensation rénale qui ne sont pas dialysés, la myasthénie, l’hypocalcémie sont des conditions qui diminue plus encore la transmission neuromusculaire. |
Nom de l’ATB
|
CEFOTAXIME (CLAFORAN®) – Céphalosporine de 3ème génération active contre les BGN, peu efficace contre les germes gram-positif, et grande
efficacité contre les germes résistants. Stoppe la synthèse de la paroi et inhibe la croissance bactérienne. Peut être utilisé en association avec METRONIDAZOLE or Clindamycine. |
Dose adulte
|
1 g IV q8-12h
|
Dose enfant
|
80-180 mg/kg/j IV en 3 à 4 fois
|
Contre-indications
|
Allergie.
|
Interactions
|
PROBENECIDE accroît l’effet de la CEFOTAXIME; co-administration avec le FUROSEMIDE et les aminoglycosides
augmente la nephrotoxicité. |
Précautions
|
Ajuster la dose en cas d’atteinte rénale; on lui reproche la survenue de colites
|
It is best if it fails to change the antibiotic rather than increasing the dose thoughtlessly.
Gentamicin has a significant nephrotoxicity, which should be assessed by the occurrence of renal failure.
Treatment of metabolic disturbances
It seeks a balanced diet and hydroelectric satisfactory. Prevention or correction of dehydration is provided by a supply of water and electrolytes in amounts appropriate to the data of clinical and biological.
Maintaining proper kidney function based on the correction of circulatory abnormalities and hydro electrolyte, the use of renal replacement therapy is sometimes necessary.
Traitement des troubles de l’hémostase
Nom du médicament
|
Phytonadione (AquaMEPHYTON, Konakion, Mephyton) – Stimule la synthèse hépatique des facteurs de la coagulation
|
Dose adulte
|
5-25 mg/j VO; en alternance avec 10 mg IV/IM/SC
|
Dose enfant
|
2.5-5 mg/j PO; en alternance 1-2 mg/dose as single dose
|
Contre-indications
|
Allergie
|
Précautions
|
N’a aucun effet en cas d’hypothrombinémie héréditaire
|
Nom du médicament
|
Plasma Frais Congelé (PFC) – Le plasma est la composante liquide du sang, il contient les facteurs de coagulation. Ces indications : hémorragie
chez les personnes atteintes de coagulopathies ou déficit en plusieurs facteurs de la coagulation (atteinte hépatique sévère). |
Précautions
|
La contamination Virale et les infections sont possibles.
|
Treatment of shockThe sequence of events clearly indicates that hemodynamic hypovolemia plays a fundamental role in the onset of septic shock, so the first treatment goal should be to restore blood volume and the increase in this one as much as is necessary, but always under constant surveillance of the PVC that should remain below 10 cm of water because the risk of pulmonary edema is real [7].This treatment is based primarily on volume replacement using:
* Fresh frozen plasma + + +
* Sang HK especially if <30% (RBC)
* Albumin: Fight against hypoalbuminemia secondary to septic shock. Maintaining a normal colloid osmotic pressure to reduce the risk of PAO.
* Colloids: Plasmagel, Dextran
* Crystalloids: hypertonic saline in cases of a hydroelectric disorders and acid-baseIf signs of shock persist, and when the central venous pressure (PVC) rises above 15 cm of water demonstrates incompetence myocardial must use the cardio and vasoactive drugs:- Dopamine (2-5mg/kg/mn):
* Increases intrinsic myocardial contractility and heart rate.
* Vasodilation in the kidneys and splanchnic.
* Vasoconstriction moderate muscle and skin vessels.- Dobutamine:
* Predominantly positive inotropic action
* Little effect tachycardisant
* No renal dilatationTreatment of renal failureDefinition: Renal failure is [31]:
* Linked to decreased renal perfusion without cellular injury.
* The extension in time predisposes to the occurrence of acute tubular necrosis.
* Is rapidly reversible when the underlying cause is corrected.
* The most common form of acute renal failure.
* Frequent postoperative contexts (hypovolemia, drugs) and in the elderly because of their predisposition to hypovolemia and the presence of atherosclerotic renal disease.Regardless of any treatment of the case, the therapy of acute renal failure is inconceivable that a specialized, it focuses on the treatment of complications:Extracellular hyperhydration:Especially complicated forms oligo-anuric:* Diet: fluid restriction <500 ml / day, sodium and 4 g / d;* Loop diuretic: Furosemide in high doses;* On failure and persistent anuria in 24 hours, indicative of renal replacement therapy with ultrafiltration.Metabolic acidosis:- To correct if decompensated or if clinical impact.- Need to correct hypocalcemia in advance because of increased risk.In the absence of congestive heart failure or pulmonary edema:* Infusion of sodium bicarbonate.- If it is severe (bicarbonate = 10 mmol / l), indicative of renal replacement therapy by hemodialysis.Fight against hyperkalemia (KAYEXALATE ®).Correction of hypocalcemia and hyperphosphatemia:- Administration of calcium carbonate.- These disorders are effectively treated in an institution of renal replacement therapy.Indications for renal replacement therapy?In emergencies, when the prognosis is at stakeIn contexts of severe ARI, anuric, with the following events:
* Hyperhydratation extracellular with pulmonary edema, severe hypertension.
* Hyperkalemia symptoms (clinically or electrical anomalies).
* Severe metabolic acidosis (bicarbonate = 10 mmol / l, pH <7.2).
* Greater nitrogen retention.Presence of new-onset neuropsychiatric disorders:* Hemodialysis is the method used in emergency situations. The vascular access is obtained after implantation of deep venous catheters: internal jugular or femoral;* The first session should be brief (02 hours) to avoid severe neurological disorders associated with too rapid correction of electrolyte disturbances.
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