1、全肠道灌洗治疗急性中毒全肠道灌洗治疗急性中毒1 全肠道灌洗whole bowel irrigation 定义:通过胃管内注入大量的等渗聚乙二醇电解质溶液(PEG-ES)来诱导中毒患者排出液态粪便,目的在于清除胃肠道内未被吸收的毒物2主要内容必要性实施方案国外研究病例讨论3中毒流行病学 荟萃分析,1994.12007.9,24篇,27908例 毒物分类:药物26.5,乙醇22.8,CO 14.9,食物10.9,农药10.7,杀鼠剂4.2,亚硝酸盐2.5%自杀最常见自杀最常见(57.9(57.9),80.880.8为口服中毒为口服中毒医学综述,2008,14(15):2374-23764洗胃的实验
2、研究groupTime(min)formulationdrugrecoveryReduction AUCAnimal20liquidbarium sulfate29%30liquidbarium sulfate26%60liquidbarium sulfate8.6%Volunteer5tablet90%5liquidTc99m-DTPA80-85%10tablet45%19tablet30.3%60tabletsalicylate32%60liquidacetaminophen20%567被忽视的肠道毒物 普罗帕酮自杀中毒38例 导泻仅4例(10.5%)氯氮平中毒的临床特征和诊疗现状 成人组
3、60例,导泻10例(16.7)中国急救医学,2011,31(3):244-246 中华急诊医学杂志,2007,16(7):773-7748影响毒物吸收的因素PoisonPatientPathophysiologydose/concentrationTotal absorptive surface areaAgeAnticholinergic effects due to the poisonPhysical form:solid(immediate release,controlled release,seed),liquidSaturability of transport proteins
4、 Enterohepatic recirculationHypotension or hypothermia causing hypoperfusion to the gut HypoxaemiaPhysicochemical properties (pKa、solubility)Gastrointestinal motilityGastrointestinal milieu:food,enzymes,bacterial flora,pHGastric irritation(increased gut motility)Clin Pharmacokinet 2007;46(11):897-93
5、99清除肠道毒物的必要性 大部分经肠道吸收中毒 洗胃对毒物的清除有限 毒物的延迟吸收(缓释/控释、肠溶、转运蛋白、肠蠕动减弱、肠道低灌注/缺氧)10主要内容必要性实施方案实施方案国外研究病例讨论11适应症 经口大量摄入缓释药物或肠溶药物 口服大量铁(吸收依赖转运蛋白)消除非法药物摄入包 American Academy of Clinical Toxicology&European Association of Poisons Centres and Clinical Toxicologist Journal of Toxicology,2004,42(6):84385412潜在致命的毒物 控
6、释片/胶囊:氯化钾(补达秀)、硝苯地平(拜新同)、格列吡嗪(瑞易宁)、吗啡(美施康定)、卡左双多巴(息宁)、沙丁胺醇、扑尔敏、茶碱、尼莫地平、吲哚美辛 缓释片/胶囊:茶碱(舒弗美)、非洛地平(波依定)、格列齐特(达美康)、双氯芬酸(扶他林)、布洛芬(芬必得)、二甲双胍、硝苯地平13潜在致命的毒物 肠溶片/胶囊:阿司匹林、双氯芬酸、雷贝拉唑、奥美拉唑 铁剂:琥珀酸亚铁(速力菲)、硫酸亚铁、枸橼酸铁铵、乳酸亚铁14禁忌症 无气道保护能力且未实施气道保护者 肠穿孔 肠梗阻 胃肠道出血 血流动力学不稳定 无法控制的顽固性呕吐 American Academy of Clinical Toxicolog
7、y&European Association of Poisons Centres and Clinical Toxicologist Journal of Toxicology,2004,42(6):84385415剂量推荐 a recommended dosing schedule:Children 9 months to 6 years:500 mL/h Children 612 years:1000 mL/h Adolescents and adults:15002000 mL/h American Academy of Clinical Toxicology&European Ass
8、ociation of Poisons Centres and Clinical Toxicologist Journal of Toxicology,2004,42(6):84385416WBI的实施 鼻胃管、容器 坐位或床头抬高至少45度 粪便接受容器 胃复安、新斯的明 如果出现呕吐,将输注速度减半,3060分钟后恢复初始速度 终止:至少至结肠排出清亮液体 American Academy of Clinical Toxicology&European Association of Poisons Centres and Clinical Toxicologist Journal of T
9、oxicology,2004,42(6):84385417聚乙二醇电解质散剂(舒泰清)成分:A 剂含聚乙二醇4000 13.125g;B 剂含碳酸氢钠0.1785g,氯化钠0.3507g,氯化钾0.0466g配制:取本品A、B 两剂各一包,同溶于125l 温水中成溶液不良反应:腹泻,阵发性腹痛,大量服用可能出现恶心、腹胀,偶有腹部痉挛、呕吐和肛门不适18并发症 恶心呕吐 腹痛腹胀 吸入性肺炎19主要内容必要性实施方案国外研究病例讨论20动物研究 dog,WBI with PEG-ES 50 mL/kg/h was begun 1 hour after paraquat administrati
10、on and continued for 5 hours After the 5-hour,WBI and control plasma paraquat concentrations were 5.61.8 and 33.010.2 mg/L this procedure removed 68.9%of the ingested dose Human Exp Toxicol 1992;11:49550421志愿者研究 Three studies involving dosing with ampicillin,delayed-release aspirin and sustained-rel
11、ease lithium showed significant reduction in bioavailability of 67%,73%,and 67%Journal of Toxicology,2004,42(6):84385422临床研究 Iron,lead,arsenic,mercury,potassium sustained-release verapamil,delayed-release fenfluramine almodipine body packing:cocaine or herin Journal of Toxicology,2004,42(6):84385423
12、主要内容必要性实施方案国外研究病例讨论24Case 1 女 28岁 既往安装心脏起搏器,边缘人格 Episode 1.2年前口服KCl缓释胶囊100片(75克)3h后至ED,血钾7.2mmol/L,很快心脏骤停,CPR时静注肾上腺素后室颤,除颤后气管插管收入ICU,查血钾9.2mmol/L,起搏心律,血压90/35 mmHg.静注钙、碳酸氢钠、糖胰岛素,胃管内注入聚苯乙烯磺酸钠树脂8h内血钾 9.2 6.9 7.5 9.5 mmol/L血透4h,血钾恢复正常,2d后转心理科 No GI decontamination was performedClinical Toxicology 2008,
13、46:1102-110325Case 1 Episode 2.4.5 months later口服KCl缓释胶囊100片(75克)1h后至ED,查血钾5.1mmol/L收入ICU时起搏心律、血压140/60 mmHg,麻醉后气管插管,洗胃,入ICU2h后血钾6.9 mmol/L,静注钙、碳酸氢钠、糖胰岛素,口服聚苯乙烯磺酸钠树脂X线发现胃内大量胶囊,WBI,12h内10 L PEG-ES(胃管),排泄物中大量胶囊碎片和一些完整胶囊 血钾6.2 6.8 5.7 5.3 4.4mmol/L,24h后脱机拔管转心理科 Clinical Toxicology 2008,46:1102-110326Ca
14、se 1 Episode 3.3.70粒,2.5h至ED,血钾 7.1 mmol/L,窦律 70次/分,T波髙尖,呕吐1次(呕吐物中见4粒氯化钾),麻醉后气管插管,静注碳酸氢钠、糖胰岛素X线发现胃内大量胶囊,WBI,6 h内4 L PEG-ES,排泄物中大量胶囊碎片和一些完整胶囊 血钾 6.5 3.9 4.9 5.5 4.4 11h后腹部X线证实胃肠内无胶囊 Clinical Toxicology 2008,46:1102-11032728Case 2 A 41-year-old man ingested an arsenic-containing herbicide At 2 hours h
15、e had several bouts of emesis and diffuse abdominalpain At 4 hours,an abdominal radiograph showed radiopaque material in the small bowel WBI 2 L over 3 hours,resulted in rectal effluent with the characteristic garlic odor of arsenic and a clear radiograph Am J Emerg Med,1995,13:24424529展望 临床研究 急性农药中毒 大量药物中毒 耐受性和安全性研究 基础研究 与导泻的比较 联合活性炭后毒物的清除3031写在最后写在最后成功的基础在于好的学习习惯成功的基础在于好的学习习惯The foundation of success lies in good habits 结束语当你尽了自己的最大努力时,失败也是伟大的,所以不要放弃,坚持就是正确的。When You Do Your Best,Failure Is Great,So DonT Give Up,Stick To The End演讲人:XXXXXX 时 间:XX年XX月XX日