Posted by James White
Treatment
The presence of symptomatic pericardial fluid is an indication for drainage, not surgery. Suspected or proven tamponade is best treated by pericardiocentesis which is accomplished easily under local anesthesia. General anesthesia for an emergent drainage procedure or window in this clinical setting is dangerous and should be avoided. Patients suffering from tamponade need increased endogenous catecholamines for circulatory support. The induction of general anesthesia inhibits these protective autonomic responses and may lead to circulatory collapse before drainage can be effected. With drainage, the acute crisis of tamponade is at least postponed. Read the rest of this entry »
Posted by James White
Presentation
In cases of malignant pericardial tamponade, symptoms are nearly ubiquitous. Patient complaints are often dramatic and include syncope, chest pain, or palpitations; more subtle symptoms include dyspnea, chest heaviness, and simple fatigue. Components of the often-described clinical triad of hypotension, tachycardia, and muffled heart tones are usually present. These physical findings, along with distended neck veins and a pulsus paradoxus, lead to a diagnosis of tamponade. Impaired venous return from elevated pericardial pressure leads to inadequate right heart filling and decreased stroke volume. In an effort to maintain cardiac output, the host manifests a chronotropic response until preload becomes limiting. Without intervention at this advanced stage, patients may show all the hallmarks of a low-output shock state, including cold, clammy skin, oliguria, and altered mental status. The severity of these signs and symptoms and the history of a prior malignancy will dictate the urgency for diagnostic and therapeutic intervention. www.mycanadianpharmacy.com
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Posted by James White
Talc is also a more attractive sclerosing agent when cost is analyzed. Review of our inpatient pharmacy charges for the currently available sclerosing agents showed bleomycin (60 U, $3,680) was 65 times as costly as talc (4 g, $56). Doxycycline (1,000 mg, $120) was more reasonably priced but still more than two times the talc expense. my canadian pharmacy.com
As talc appears to be the most efficacious and cost-effective sclerosant, the remaining controversies center on the route of delivery. Most of the published experience with talc involves intraoperative insufflation of the agent as a fine powder. The operator can, at the same time, ensure all fluid has been drained, lyse any restricting adhesions, break up loculated collections, and visually confirm adequate disbursal of the talc. In contrast, Chambers in 1958 and Webb et al in 1992 demonstrated 85 to 100% effective control of MPE administering talc as a slurry through a chest tube at the patient’s bedside. Read the rest of this entry »
Posted by James White
Cytogenetic analysis of pleural fluids has proved beneficial in difficult-to-diagnose cases. This process involves analyzing the chromosomes of cells in an effort to determine rearrangements or deletions that characterize certain tumors. We have also found cytogenetic analysis useful to differentiate carcinomas from the epithelial subtype of mesothelioma. These studies may increase diagnostic sensitivity to close to 90%. The assay, however, is not universally available and takes 5 to 7 days to complete. canadian-familypharmacy.com
Despite all currently available fluid analyses, the etiology of a small percentage of effusions remains unknown. Thoracoscopy or pleuroscopy is then indicated to establish a definitive diagnosis. Over a 3-year period, we used this minimally invasive technique to evaluate and treat 196 patients with symptomatic pleural processes. A definitive etiology was confirmed for each case (though some were known preoperatively). Half of these cases involved malignancy. Read the rest of this entry »
Posted by James White
Simple posteroanterior and lateral chest radiographs mav detect effusions as small as 200 mL. In addition, viewing the chest with the patient in a lateral decubital position allows better localization of small to moderate fluid accumulation and may guide diagnostic sampling. When the fluid does not layer dependently with change in patient position, loculation should be suspected. Ultrasound or CT is then particularly useful in defining the anatomy, as well as the safest approach to diagnosis and therapy. Read the rest of this entry »
Posted by James White
Epidemiology
Almost all forms of cancer are reported to cause pleural effusions. In their review, Hausheer and Yarbro summarized six large series of malignant pleural effusions (MPEs). In aggregate, they found over two thirds of all malignant effusions were attributed to carcinomas of the lung (35%) and breast (23%) and to lymphoma (10%). The next most common etiology was adenocarcinoma of unknown primary, accounting for 95 of 811 cases (12%). Given the prevalence of breast and lung carcinoma, it is not surprising that some investigators report up to 50% of patients afflicted with these malignancies will develop MPE at some time during their disease. Such observations are currently 2 to 4 decades old, and have been criticized as being outdated given oncologic advances. This may be valid regarding breast cancer treatment, in which survival has been much improved. Alternatively, longer survival may unmask or allow for more recurrences, including those within the pleura. As for lung cancer, the incidence of this malignancy continues to rise with little improvement in effective therapies for advanced disease. Therefore, little reason exists to doubt the lung cancer MPE data from past decades. canadian health&care mall
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Posted by James White
Malignant fluid collections within the pleura and/or pericardium are common oncologic dilemmas. These effusions are frequently symptomatic and, in the case of the pleural space, may be the presenting sign of cancer. In other patients, they represent markers of recurrent, disseminated, or advanced disease. Pleural or pericardial effusions require rapid diagnosis and, if symptomatic, expeditious management. External drainage usually leads to a discrete diagnosis and temporarily relieves symptoms, yet definitive therapy is often more complex and may involve interventional radiology, cardiology, and thoracic surgery, as well as medical and radiation oncology. Permanent drainage and/or obliteration of the pleural or pericardial space are the keys to definitive treatment of the effusion and will provide long-standing palliation. Clinicians must acknowledge the grave prognosis facing most patients with these conditions—as their malignancies are, by definition, advanced—and must strive for the least morbid route toward diagnosis and durable palliation. Read the rest of this entry »