假酒(甲醇)中毒治療@ 急診小醫師 - 隨意窩

201901200040假酒(甲醇)中毒治療 · 1. BICARBONATE 可抑制甲酸進入細胞內. · 2. 及早給予解毒劑fomepizole (抑制ADH)，若無法取得fomepizole 才選用乙醇來治療, 對於已經產生 ... 急診小醫師https://dictionary.cambridge.org/zht/日誌相簿影音好友名片 201901200040假酒(甲醇)中毒治療?毒物_環境急症甲醇在體內會透過過乙醇去氫酶(alcoholdehydrogenase，ADH)和醛去氫酶(aldehydedehydrogenase，ALDH)代謝成甲酸,甲酸是造成全身毒性的主要物質,  1.BICARBONATE可抑制甲酸進入細胞內.  2.及早給予解毒劑fomepizole(抑制ADH)，若無法取得fomepizole才選用乙醇來治療,對於已經產生的甲酸,則無效 3.乙醇可以拮抗甲醇毒性.但對於已經產生的甲酸,則無效. 需每1至2小時監測乙醇的血中濃度是否有在建議的療效範圍100-150mg/dL 4.甲醇吸收很快,腸胃道去污效果有限,除非喝入60分鐘內,胃裡面還有很多甲醇,可考慮放NGtube抽吸,否則不建議催吐或洗胃,不建議給予活性碳 5.血液透析可去除甲醇.但並非所有病患都需透析.  酸性環境會讓甲酸鹽解離成不帶電荷的甲酸,不帶電荷甲酸較容易穿透細胞膜,校正酸血症有助於避免不帶電荷甲酸穿透細胞膜,進入末端組織內.  end-organtissues(suchastheretina) 例如視網膜.不帶電荷甲酸也容易在尿中被腎細胞重新吸收回血中,理論上,鹼化血液可避免甲酸進入細胞內,且有助於甲酸經尿液排除.但目前並沒有更多證據確認是否該給予重碳酸,建議當病患酸鹼值<7.3的時候可以給予3-6ampBICARBONATE(1to2meq/kg) BICARBONATE維持劑量.4ampBICARBONATEinD5W500CCrun150-250cc/HR.小兒可加倍滴速(根據體重算劑量).最佳速率依照病患起始酸鹼值.體液量,血鈉濃度調整.治療目標.pH>7.35 關閉點滴.  Despitethisclearrationale,noclearevidenceexiststodeterminehowbicarbonateshouldbegiven.Wesuggestinitialtreatmentwith1to2meq/kgofsodiumbicarbonateviaIVbolusforanypatientwithapHbelow7.3.  Amaintenanceinfusionisthenpreparedbymixingapproximately133meqofsodiumbicarbonatein1literofD5W.Infusionratesmayrangefrom150to250mL/hourinadults,oronetotwotimesthemaintenancefluidrateinchildren.TheappropriateratedependsupontheinitialpH,andsuchparametersasfluidstatusandserumsodiumconcentration.ThegoaloftreatmentismaintenanceofanarterialorvenouspHabove7.35,atwhichpointtheinfusionisdiscontinued. Ethanol—Historically,ethanolhasbeenusedasacompetitiveinhibitorofADH,asADHhasgreateraffinityforethanolthanformethanolorethyleneglycol.Althougheffective,intravenousethanoltreatmentcreatesseveralproblems: ●Ethanolisdifficulttodose,andappropriatelevelsaredifficulttomaintain;asaresult,frequenttestingandinfusionadjustmentsareoftenrequired. ●Ethanolrequirescompoundingbythehospitalpharmacy,irritatesveinswheninfused,andcancomplicatefluidbalanceinoliguricpatients. ●Mostlimitingarethesedativeandbehavioraleffectsofethanol,whichcancauseobtundation,therebyincreasingtheriskofaspiration,andothercomplications. ●Ethanoltherapymayposesignificantrisksincertainpatients(eg,uppergastrointestinalbleeding,firsttrimesterpregnancy). Hemodialysis—Hemodialysisisthebestmethodtorapidlyremovebothtoxicacidmetabolitesandparentalcohols,anditplaysafundamentalroleintreatingseverelypoisonedpatients[18,35,56].Emergencycliniciansshouldinitiateconsultationwithanephrologistimmediatelyiftheysuspectatoxicalcoholingestionandthepatienthasevidenceofend-organdysfunctionoracidemia,especiallyiftransfertoahemodialysiscentermaybenecessary. Insuchcases,consultationshouldnotbedelayeduntilconfirmatorymethanolorethyleneglycollevelsareobtained.Anarterialorvenousbloodgasservesasanessentialtriagetoolinthissetting.Thisisparticularlytruewhencaringsimultaneouslyformultiplepoisonedpatientswithlimitedhemodialysiscapability[54,57]. Werecommendimmediatetreatmentwithhemodialysisinthesettingofaknownmethanolorethyleneglycolingestionifeitherofthefollowingconditionsispresent: ●Highaniongapmetabolicacidosis,regardlessofdruglevel ●Evidenceofend-organdamage(eg,visualchanges,renalfailure) Inaddition,wesuggesttreatmentwithhemodialysisinanypatientwithasuspectedtoxicalcoholingestionwhohasasevere,otherwiseunexplainedaniongapmetabolicacidosisandsignificantplasmaosmolalgap.Itisdifficulttoprovideprecisethresholdsfordeterminingwhenhemodialysisshouldbeperformedwhentheingestionisuncertain.Ifatoxicingestionisstronglysuspected,athresholdpHof7.30isreasonable;ifsuspicionisweaker,apHof7.10maybemoreappropriate.(See'Laboratoryevaluation'above.) Interpretingavailableclinicalinformation(eg,natureandintentofexposure,pH,osmolarity)todecidewhethertoinitiatehemodialysiscanbechallengingwhenconfirmatorymethanolandethyleneglycolconcentrationsareunavailable[21].Weencouragecliniciansfacingthisdifficultytoconsultwithapoisoncontrolcenter,medicaltoxicologist,orotherphysicianexperiencedinthemanagementofsuspectedtoxicalcoholexposure. Fornonacidemicpatients,hemodialysiscanbeusedtocleartheparentalcoholandabbreviatethecourseofantidotaltherapy.ThereislessurgencytotreatwithhemodialysisifADHinhibitionisadequate.Hemodialysisisoftenunnecessaryinpatientswithunmetabolizedethyleneglycolprovidedthat[18,19]: ●Fomepizoleisgiven(prolongedethanoltherapyisimpractical) ●TheserumpHisnormalornearnormal(ie,littleglycolateispresent) ●Theserumcreatinineremainsnormal Patientswithethyleneglycolconcentrationsgreaterthan300mg/dL[48mmol/L]havebeensuccessfullytreatedwithfomepizolealonewhentherapywasinitiatedbeforetheappearanceofacidosis.TreatmentwithhemodialysisisstillrecommendedforlargemethanolingestionsbecauseserummethanoleliminationbecomesextremelyslowwhenADHisinhibited[35,58,59]. Thehemodialysisprescriptionshouldincludealargesurfaceareadialyzer(>1.5m²),abloodflowrateinexcessof300mL/min,andabicarbonatebath.HemodialysisshouldcontinueuntiltheserumpHisnormalandparentalcoholconcentrationsarelessthanapproximately25mg/dLor5mmol/L.Thedurationofhemodialysisinhourscanbeestimatedusingtheformula-Vln(5/A)/0.06k,whereVistotalbodywaterinliters,Aistheinitialalcoholconcentrationinmmol/L,andkis80percentofthedialyzerureaclearanceinmL/minattheobservedbloodflowrate[60-62].Suchacalculationprovidesonlyanestimate,andthepatient’sclinicalconditionwillalsoaffectthedosingofhemodialysis.Serumalcoholconcentrationsandacid-basestatusshouldalwaysbeverifiedneartheendofhemodialysisandagaintwohourspost-hemodialysistoascertaintheadequacyoftreatment[21].(See"Acutehemodialysisprescription".) Morethanoneroundofhemodialysismaybenecessaryinmassiveoverdosesandforethyleneglycol-poisonedpatientswithrenalfailure.Renalfunctionoftenrecoversoveraperiodofdaystomonthsinsurvivorsofethyleneglycolpoisoning. Fomepizoleisdialyzable,andthefrequencyofitsdosingshouldbeincreasedtoeveryfourhoursduringhemodialysis.Anadditionaldoseshouldbegivenatthebeginningofhemodialysisifsixormorehourshaveelapsedsincethepriordose. Ifethanolisusedforalcoholdehydrogenase(ADH)inhibition,adjustmentsinthedosemustbemadeduringhemodialysis.Afallinethanollevelscanbeavoidedoramelioratedbyincreasingtherateofethanolinfusionandpossiblybyaddingethanoldirectlytothedialysate[63,64].Inonesuchcase,adialysateethanolconcentrationof100mg/dLwaspreparedbyadministeringa95percentethanolsolutionintothedialysateinlettubingatarateof40mL/hviaaninfusionpump.Thedialysateflowratewasmaintainedat500mL/min,andthedialyzerbloodflowaveraged280mL/min.Anaverageplasmaethanollevelof90mg/dLwasobtainedduringthesix-hourhemodialysissession. Peritonealdialysisandotherformsofcontinuousrenalreplacementtherapyareinefficientatclearingtoxicalcoholsandtheirmetabolitesandarenotrecommended[21]. 參考資料 1.UPTODATE 2. 甲醇與乙二醇中毒之治療華宇藥品股份有限公司藥師吳芊樺、黃俊瑋、林亮光 Ethanol—Historically,ethanolhasbeenusedasacompetitiveinhibitorofADH,asADHhasgreateraffinityforethanolthanformethanolorethyleneglycol.Althougheffective[54,55],intravenousethanoltreatmentcreatesseveralproblems:●Ethanolisdifficulttodose,andappropriatelevelsaredifficulttomaintain;asaresult,frequenttestingandinfusionadjustmentsareoftenrequired.●Ethanolrequirescompoundingbythehospitalpharmacy,irritatesveinswheninfused,andcancomplicatefluidbalanceinoliguricpatients.●Mostlimitingarethesedativeandbehavioraleffectsofethanol,whichcancauseobtundation,therebyincreasingtheriskofaspiration,andothercomplications[52].●Ethanoltherapymayposesignificantrisksincertainpatients(eg,uppergastrointestinalbleeding,firsttrimesterpregnancy).Ethanol—Historically,ethanolhasbeenusedasacompetitiveinhibitorofADH,asADHhasgreateraffinityforethanolthanformethanolorethyleneglycol.Althougheffective[54,55],intravenousethanoltreatmentcreatesseveralproblems:●Ethanolisdifficulttodose,andappropriatelevelsaredifficulttomaintain;asaresult,frequenttestingandinfusionadjustmentsareoftenrequired.●Ethanolrequirescompoundingbythehospitalpharmacy,irritatesveinswheninfused,andcancomplicatefluidbalanceinoliguricpatients.●Mostlimitingarethesedativeandbehavioraleffectsofethanol,whichcancauseobtundation,therebyincreasingtheriskofaspiration,andothercomplications[52].●Ethanoltherapymayposesignificantrisksincertainpatients(eg,uppergastrointestinalbleeding,firsttrimesterpregnancy).Toapproveasinglesuggestion,mouseoveritandclick"✔" Clickthebubbletoapproveallofitssuggestions. 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