Ayurvedic treatment procedure siravedha/venesection

 SIRAVEDHA/ VENSECTION

            Siravedha or venesection  is the major operation when compared with the other raktamoksha techniques in Ayurveda. Here the blood is let out from circulating venous blood. Results are immediate and long last.

•  Aim: letting off blood which is put under pressure by a tourniquet.
•  NOTES: this technique needs proper care and attention. Also requires proper knowledge of vascular system and the distribution of  veins in our body. Care should be taken to prevent excess bleeding. Emergency setup should be made ready if in need to meet shock & other complications.

Classical method of siravédha was not popularized because of the rough nature of the procedure and chance of complication. Now a day’s modified siravedha with scalp vein set has got much popularity.

Effects and importance:

• Anti-inflammatory effect 
• Pain relieving effect.
•  Reduce venous congestion. 
• Act as preventive and curative treatment modality. 
• Very helpful to treat some chronic disease conditions which are not cured by pancakarma and samana oushadhas. Used as an emergency treatment modality in some particular disease condition like snake bite, increased IOP etc
• Siravedha cures all diseases from their roots just like rice & other crops in the field die out completely by cutting the channels of water supplying to the field.
• Siravédha is considered as half treatment or even full treatment in ancient surgery( salyatantra), described for all  '

INDICATIONS:generalised skin diseases like psoriasis, eczema etc, aching pain, cervical spondylosis, chronic head ache, vascular head ache, hypertension, radiculopathy, frozen shoulder after injury, sciatica, RA, scleritis, post chikungunya arthritis, recurrent abscesses all over the body, chronic whole body itching, allergic skin rashes, cutaneous vasculitis, some psychiatric diseases, varicose vein, chronic varicose ulcer, chronic non healing ulcers etc

’In emergencies like in poisonous conditions siravédha is indicated.

CONTRA INDICATIONS:, person below the age of 16 yrs'and above the age of 70 yrs, pregnant ladies, person with generalized oedema, bleeding disorders, severe anaemia, hypotension, patients with severe diarrhoea, ascitis, women after delivery etc 

Materials required:

Toumiquet Cotton & Gauze

Surgical blade Anticoagulant (sodium citrate) . Scalp vein set/ butterfly needle. Iodine solution (anti-septic) Spirit Tray

Gloves Artery forceps

. Prior to the procedure. Massage with suitable oil should be done over the area and after that fomentation should be clone .Better to cover the patient‘s eye with a cloth.

PROCEDURE-a tourniquet is tied about 4CMSover the sira/ vein to which the procedure is performed. Locate and elevate the vein with maximum tension. Place the tip of the surgical blade on the vein. Exerting a trigger force on the blade/ single stroke with the blade on the particular vein should be done. The blood

will rush  like a fountain stream. Blood is collected in the basin which is added with anti-coagulant

solution, as required

Amount of blood drawn:practically about 100 ml-200 ml at a time. 

Below 100 ml is subliminal threshold for stimulating homepoesis.

 Post operative procedures when required amount of blood is collected or if the bleeding stops, the crepe bandage is released. Clean the area with cotton soaked in triphala ks and dress or bandage healing oil or ghee and gauze.  In case the bleeding does not stop, wet and tight bandage helps to arrest bleeding.

•  Precautions-veins may slippery and hence surgeon should be cautious in applying surgical blade.
• Better to check patient’s vital signs (BP, pulse, respiratory rate etc) before and alter the procedure.
• The vein should not be cut, but it should be punctured. 
• Care should be taken to ensure proper aseptic environment and instruments.
• Care should be taken to prevent excess bleeding. 
• Emergency setup should be made ready it'in need to meet shock & other emergencies
•  

MODIFIED SIRAVEDHA:patient should lie on the table. Select the vein to be punctured Apply tourniquet tightly above the site of puncture. The area is cleaned with spirit and cotton The needle

scalp vein set is to be inserted to the desired vein. The flowing blood is collected in  beaker contain

anti-coagulant. When blood flow reduces remove the tourniquet and scalp vein set. Apply bandage e

the punctured area. The patient is advised to take rest for 15-20 mts Usually 100450 ml blood is to out by this method.

malignant neoplasm ovary - Dysgerminoma

Germ cell tumours constitute about 15-20 per cent of all ovarian neoplasm and they are the second common ovarian tumours. For classification see p. 281. They have got varying degrees of malignant potentiality. About 3 per cent of these tumours are malignant. Germ cell tumours occur predominantly in children and young adults. They arise from embryonic germ cells.

Dysgerminoma

                       Dysgerminoma is the commonest (30-40%) malignant germ cell tumour. It arises from undifferentiated form of germ cells. It is often (5%) associated with dysgenetic gonad (see Ch. 27). The counter part of dysgerminoma in male is seminoma. ‘Majority (75%) of the tumours occur before the age of 30 years.

hCG assays are often positive, confusing the diagnosis with pregnancy. It may coexist with pregnancy (20-30%). Dysgerminoma may be associated with choriocarcinoma or endodermal sinus tumour. Tumour markers a-fetoprotein (AFP) and hCG may be positive in that situation. Karyotyping is needed specially when a premenarcheal girl presents with a pelvic mass.

Pathology: The shape is usually round or oval and is usually 5-15 cm in diameter; feel is boggy, at times it is firm rubbery. It may be bilateral (10%). Cut section shows pink or yellow colour. Microscopic appearance reveals uniform large round cells (monotonous pattern), arranged in cords or clumps with abundant clear cytoplasm. Nuclei are large, irregular and hyperchromatic with varying degree of mitosis. There is intense infiltration of lympho~ Cytes and plasma cells in the fibrous septum (Fig. 23.25). In more than 50 per cent, they are potentially malignant.

Clinical features are not specific for the tumour.

Treatment: Majority (75%) of dysgerminomas are Confined to one ovary and are stage I at the time of diagnosis.

In a young patient where preservation of fertility is desired, laparotomy for surgical staging and unilateral salpingo-oophorectomy’ is' done. If there is any suspicion of involvement to the other ovary, bisection of the contralateral ovary, and excisional biopsy should be done. The tumour is sensitive to both chemotherapy and radiotherpy

Medications for hiv treatment

Treatment:

• Preventive          
• Definitive
  

Preventive measures include:

•  Safer sex’ practice by health education. Use of latext condoms and spermicides will prevent HIV.
• Use of blunt tipped needles to avoid needle stick injury during surgery. 
•  HIV negative blood transfusion (screening of 'donors).
•  HIV negative frozen semen to use for artificial donor insemination.
• 'To maintain protocols for correct handling of all body fluids 
• 'Postexposure prophylaxis with zidovudine and lamivudine is advisable.
• 'Termination of pregnancy in HIV positive women.
• Avoiding breastfeeding -in the developing world, avoidance of breastfeeding may not be possible. Mother needs to be counselled
• as regard the risks and benefits of breastfeeding. She is helped to make an informed choice. . ' .'
• 'Wide spread voluntary counselling and testing
• 
  

Definitive

HIV treatment protocols change frequently.

Antiretroviral therapy

: Antiretroviral drugs are grouped into -

 (A) Nucleoside Reverse Transcriptase Inhibitors (NRTIS) : Zidovudine, Zalcitabine, Lamivudine, Stavudine.

 (B) Non-Nucleoeide ReverseTranscriptase Inhibitors (NNRTIS) : Delvirdine, levirapine, Efavirenz.

 (C) Protease Inhibitors (PI) : Indinavir, Saquinavir, Ritonavir, Amprenavir

. D) Fusion inhibitor : Enfuvirtide. The combinations of these drugs are effective in increasing CD4 counts and reducing viral load. Monotherapy is not used as it hastens drug resistance. Combination therapy is known by the acronym HAART (Highly Active Antiretroviral Therapy).

Drug combinations :

• Up to date treatment recommendations available at: www.A.IDSinfo.nih.gov.
•  Two from Gr. A (NRTIs) plus one from Gr. 8 OR 2 from Gr. A (NRTls) plus one from Gr. C (PI).
• Plasma HIV RNA levels indicate the degree of viral replication and CD4 + T cell count indicate level of immune competence.
• Important side effects of drugs - lactic acidosis, anemia, granulocytopenia, pancreatitis, peripheral neuropathy, hepatic dysfuncction and carbohydrate intolerance

. 

When to start therapy: 

• Acute HIV infection syndrome. 
• Symptomatic HIV infection.
• Asymptomatic but CD 4 cell count < 350cells/id or with viral load HIV RNA 50,000 copies/ml.
•  Post-exposure prophylaxis 
• With effective treatment viral load should reach 'undetectable’ levels (< 50 copies/ml) and CD4 count should rise.
•  Patients with CD 4 count < 200/ Ml should also receive trimethoprim and aulphamethoxazole combination ( carinii prophylaxis).
•  Opportunistic infections (mycobacterium) should be treated simultaneously with specific drugs when CD4 + T cells < 50/ul.
•  Colposcopy and cervical cytology screening should be routinely done.
• Zidovudine is given in a dose of 200 mg every 8 hours. Nevirapine is found to reduce the viral transmission to breastfed infants.

When to change

 (i) Failure to reduce viral load.

 ii) Persistently declining CD43 + T cell count.

 (iii) Clinical deterioration.

Postexposure Prophylaxis 

          A combination of2 NRITs is given for 4 weeks. Prophylactic use zidoudine (300 mg bid) and lamivudine (150 mg bid) for a period of 4 weeks immediately followig an exposure may reduce the  risk of seroconversion (CDC-2001).

.‘

Head massage

Abhyanga (massage) procedure performed on head (siras) is called sirobhyanga. It is the first procedure among the murdha tailas and has the less effect of all of them according to Acarya. In our common practice, prior to whole body massage,head massage is done routinely.

It can be done as a preventive procedure and as a therapeutic procedure.

Depth of penetration is about 3 mm.

'Reference seen in Ayurveda  samhitas

.

Benefits of head massage

• .     Massage on temples improves eyesight and creates a well centred state of awareness.
•       Massage of the temples, eye brows relaxes the whole body and is especially beneficial for the eyes and            nervous system.
•       Massage of the forehead increases sight and power of concentration.
•       Scalp massage cures dryness, loss of hair and premature baldness. 
•       Head massage increases the supply of fresh oxygen and glucose to the brain. It increases blood                      circulation and normal functioning of hormones.

 Indications: 

            Hair fall,  Psychological diseases, headache spectrum, hair ailments, scalp diseases, degenerative and demyelinating brain diseases, ear and eye diseases etc

Pre operative procedure: 

             It can be done at any time of the day, before bath. Morning time is most ideal. Patient is asked to take moderate warming up exercise and do clear his bowel.

Procedure: 

         Patient is made to sit on a cushioned knee high chair / stool. His body is covered with a cloth below the neck. Therapist standing behind the patient is ideal position to carry out massage. Oil is to be made Luke warm by keeping in boiling water before application. The oil is then poured in the hands of therapist,held over the head or the patient, then spread all over the head including the neck and ear pinna with palmar surface of the therapist. Then start to massage gently over these areas. Movement should be done in linear direction or  in circular fashion. 

Amount of oil to be used is till the head gets wet with oil (50 ml-lOO ml)

Duration: 30 min to 45 min. 

Medicine Pet

PET is based on the tissue uptake of 18F-fluro-2 deoxyglucose. FDG-PET can measure the difference between the normal tissue and cancerous tissue. Cancer tissues process this glucose analog differently compared to that of normal tissues. This glucose analog is given IV. FDG-PET scan is then done and the images are interpreted.

FDG-PET scan is more sensitive for detection of metastatic disease and recurrence of ovarian malignancy. It is also useful to assess the response following tumour therapy. FDG-PET scan is found to be more sensitive and specific compared to CTor MRI.

Tumour makerbreast

A tumour marker is a substance that is selectively graduated by the neoplastic tissue. It is then released into the blood where from it can be detected.

Ideal tumour marker should fulfil. the following criteria:

• .It should be produced only by the tumour cells.
•  If Should be Specific.
• Its measurement either in the blood or urine should be sensitive enough to detect microscopic or sub clinical disease.
•  Tumour markers are used to monitor the response of therapy. Ideally the antigen (tumour marker) level should represent the tumour volume correctly. Progressive rise in marker value indicates ineffective chemotherapy.
•  The assay should be inexpensive and acceptable.

The tumour marker should not only indicate the presence but also the site of tumour origin

.

      Tumour marker is useful in screening, diagnosis and management of a case and for follow up. However, the detection of tumour marker is seldom made before the cell population becomes 1010.

(The role of serum CA-125 in the evaluation of disease (ovarian carcinoma) progression and regression is invaluable. Similarly, serum BhCG is useful in the diagnosis, management and follow up of cases with GTN.)

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