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1、全肠道灌洗治疗急性中毒全肠道灌洗治疗急性中毒全肠道灌洗wholebowelirrigation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主要内容必要性实施方案国外研究病例讨论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):2374-2376洗胃的实验研究groupT
2、ime(min)formulationdrugrecoveryReduction AUCAnimal20liquidbarium sulfate29%30liquidbarium sulfate26%60liquidbarium sulfate8.6%Volunteer5tablet90%5liquidTc99m-DTPA80-85%10tablet45%19tablet30.3%60tabletsalicylate32%60liquidacetaminophen20%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60例,导泻10例(16
3、.7) 中国急救医学,2011,31(3):244-246 中华急诊医学杂志,2007,16(7):773-774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 Entero
4、hepatic 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): 897-9
5、39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)主要内容必要性实施方案实施方案国外研究病例讨论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):843854潜在致命的毒物控释片/胶囊:氯化钾
6、(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 Toxicology & European Associa
7、tion of Poisons Centres and Clinical Toxicologist Journal of Toxicology, 2004,42(6):843854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 Association of P
8、oisons Centres and Clinical Toxicologist Journal of Toxicology, 2004,42(6):843854WBI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 Toxicology, 2004,42
9、(6):843854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、呕吐和肛门不适并发症恶心呕吐腹痛腹胀吸入性肺炎主要内容必要性实施方案国外研究病例讨论动物研究 dog, WBI with PEG-ES 50 mL/kg/h was begun 1 hour after paraquat administration and continued for 5 hour
10、sAfter the 5-hour,WBI and control plasma paraquat concentrations were 5.61.8 and 33.010.2 mg/Lthis procedure removed 68.9% of the ingested dose Human Exp Toxicol 1992;11:495504志愿者研究Three studies involving dosing with ampicillin, delayed-release aspirin and sustained-release lithium showed significan
11、t reduction in bioavailability of 67%, 73%, and 67% Journal of Toxicology, 2004,42(6):843854临床研究Iron, lead, arsenic, mercury, potassiumsustained-release verapamil, delayed-release fenfluraminealmodipinebody packing: cocaine or herin Journal of Toxicology, 2004,42(6):843854主要内容必要性实施方案国外研究病例讨论Case 1 女
12、 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 2008,46 :1102-1103Case 1 Episo
13、de 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 :1102-1103Case 1 Episode 3. 3. 70
14、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 :1102-1103Case 2 A 41-year-old man ingested an arsenic-containing herbicideAt 2 hours he had several bout
15、s of emesis and diffuse abdominalpainAt 4 hours, an abdominal radiograph showed radiopaque material in the small bowelWBI 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, 13:244245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釜底抽薪-中毒治疗成功的关键