Maƙala
Methylene blue don vasoplegia da shok na sepsis: abin da gwaje-gwajen asibiti suka nuna
Wani mara lafiya ya fito daga ɗakin tiyata bayan aikin zuciya; yawan jinin da zuciyarsa ke turawa yana daidai, amma matsin jininsa ba ya tsayawa yadda ya kamata. A wani gadon kuma, mara lafiya mai tsananin kamuwa da cuta yana buƙatar ƙarin adadin norepinephrine akai-akai domin matsin jininsa ya kasance sama da matakin da aka sa a gaba. A duka yanayin biyu, jijiyoyin jini sun rasa ƙarfin matsewarsu, kuma wannan ya sa likitocin kulawa ta musamman suka gwada methylene blue. Wannan labarin yana bitar ainihin abubuwan da gwaje-gwajen asibiti suka gwada da abin da suka gano.
Bambance-bambance biyu ne suka tsara duk abin da ke ƙasa. Na farko, vasoplegia bayan tiyatar zuciya da shok na sepsis yanayin cuta ne mabambanta, tare da tsarin gwaje-gwaje mabambanta, don haka kowannensu yana da sashensa. Na biyu, rage buƙatar magungunan ƙara matsin jini ba daidai yake da ƙara yawan masu tsira ba. Yawancin gwaje-gwajen sun auna na farko; kusan babu wanda ya isa girma domin tabbatar da na biyu.
Dalilin da methylene blue zai iya ƙara ƙarfin matsewar jijiyoyin jini
Jijiyoyin arteri suna ƙuntatawa da faɗaɗawa yayin da tsokokinsu marasa layi-layi suke matsewa da sakewa, kuma faɗin waɗannan jijiyoyi ne ke ƙayyade babban ɓangare na juriyar jijiyoyin jini a dukkan jiki. Wata hanyar siginar sakewar tsoka tana farawa daga nitric oxide, ta bi soluble guanylate cyclase zuwa cyclic GMP, wanda ke ƙarfafa sakewar tsoka. Methylene blue yana tsoma baki a wannan hanya, shi ya sa zai iya hana tsananin faɗaɗar jijiyoyin jini da ke faruwa a shok. Tasirin maganin ya wuce toshe abu guda kawai: a aikin gwaji kan samar da nitric oxide da sakewar jijiyoyin jini, methylene blue ya yi tasiri a wurare fiye da ɗaya a jerin isar da siginar. Wannan aikin yana bayyana wata hanyar aiki mai yiwuwa. Ba ya hasashen yadda matsin jinin kowane mara lafiya zai amsa.
Duk gwaje-gwajen da ke ƙasa sun yi amfani da methylene blue ta jijiya a asibiti, a matsayin ƙari ga kulawa ta musamman ta yau da kullum. Babu wani abu a nan da ya gwada samfurin da ake sha ta baki a gida.
Vasoplegia bayan tiyatar zuciya
Vasoplegia a nan tana nufin tsananin raguwar ƙarfin matsewar jijiyoyin jini bayan amfani da na'urar da ke gudanar da aikin zuciya da huhu a lokacin tiyata: ƙarancin matsin jini da ƙarancin juriya duk da cewa yawan jinin da zuciya ke turawa bai ragu ba. Shaidar gwaje-gwajen da aka raba mahalarta zuwa rukuni bisa bazuwar zaɓi, domin magance vasoplegia da ta riga ta faru, ta fi dogara kan ƙaramin gwaji guda ɗaya. Wasu gwaje-gwaje biyu sun gwada methylene blue kafin tiyata ko a lokacinta domin hana vasoplegia, wanda kuwa wata tambayar asibiti ce dabam.
A gwajin Levin da abokan aikinsa na vasoplegia da ta riga ta faru bayan tiyata, inda aka raba mahalarta bisa bazuwar zaɓi, an ware marasa lafiya 56 domin a ba su 1.5 mg/kg ta jijiya a tsawon awa ɗaya ko kuma maganin bogi. Vasoplegia ta gushe da sauri a rukunin da ya karɓi maganin, yayin da 8 daga cikin 28 da suka karɓi maganin bogi suka ci gaba da samun vasoplegia bayan awa 48, kuma mace-mace sun kasance 0 daga cikin 28 idan aka kwatanta da 6 daga cikin 28. Sakamakon kawar da shok yana jan hankali, amma marasa lafiya 56 ba su isa tabbatar da tasiri kan tsira ba, kuma bambancin mace-macen bai da ƙarfi da za a iya ɗauka cewa zai shafi sauran marasa lafiya gaba ɗaya.
Gwaje-gwajen rigakafi sun nuna sakamako gauraye. A binciken Ozal da abokan aikinsa kan marasa lafiya masu babban haɗari da aka yi wa tiyatar samar da sabuwar hanyar jini ga zuciya, bayar da maganin ta jijiya kafin tiyata ya rage vasoplegia daga 13 cikin 50 zuwa 0 cikin 50. Maslow da abokan aikinsa sun gano tasiri na ɗan gajeren lokaci yayin amfani da na'urar zuciya da huhu a lokacin tiyata, yayin da Cho da abokan aikinsa kusan ba su gano wata fa'ida ga zagayawar jini ko rage buƙatar magungunan ƙara matsin jini ba. Ya kamata a karanta rigakafi a wasu zaɓaɓɓun marasa lafiyar tiyata da kuma magance vasoplegia da ta riga ta faru a matsayin ikirari biyu dabam, kowanne da nasa shaidar.
Shok na sepsis
Shok na sepsis yana haɗa kamuwa da cuta da gazawar zagayawar jini da ke ci gaba ko bayan an ba da ruwa ta jijiya, don haka norepinephrine ya zama ginshiƙin kulawa, kuma gwaje-gwajen suna tambayar ko methylene blue yana rage tsawon lokacin amfani da catecholamine. Sakamakon ya fi nuna daidaito fiye da na tiyata, amma har yanzu yana bambanta tsakanin gwaje-gwaje, kuma ya shafi rage buƙatar magungunan ƙara matsin jini ne, ba tsira ba.
Babban gwajin zamani shi ne binciken Ibarra-Estrada da abokan aikinsa na 2023 kan fara methylene blue da wuri a matsayin ƙarin magani, inda aka raba mahalarta bisa bazuwar zaɓi. A cikinsa, manya 91 da aka haɗa a nazarin sun karɓi maganin ta jijiya na tsawon awa shida kullum, har sau uku, ko kuma maganin bogi mai kama da shi, a matsayin ƙari ga norepinephrine, hydrocortisone, da vasopressin idan an ga buƙata. Lokacin tsakiyar rarraba bayanai har zuwa daina magungunan ƙara matsin jini ya kasance awa 69 idan aka kwatanta da awa 94, yayin da mace-mace da tsawon lokacin amfani da na'urar taimakon numfashi suka yi kama. Gwaje-gwajen farko sun fi ƙanƙanta: gwajin farko na Kirov da abokan aikinsa a marasa lafiya 20 ya nuna babban raguwar catecholamine bayan bayar da 2 mg/kg lokaci guda da sauri, sannan a ci gaba da bayarwa ta jijiya da adadin da ake ƙarawa. Memis da abokan aikinsa kuma sun gano matsakaicin matsin jini a jijiyoyin arteri ya fi girma bayan bayar da maganin ta jijiya (85 idan aka kwatanta da 74 mmHg), amma ba su da ma'aunin sakamako na rage buƙatar magungunan ƙara matsin jini. Sabanin waɗannan, gwajin Dong da abokan aikinsa a marasa lafiya 72, wanda ya yi amfani da maganin bogi a matsayin kwatanci, bai gano wata fa'ida mai ma'ana ga norepinephrine ko matsin jini ba. Wani kwatanci kuma ya gano vasopressin ya fi methylene blue a matsayin maganin ƙara matsin jini na biyu a awa 12 da 24. Aikin tantance adadin magani na Juffermans da abokan aikinsa ya nuna matsin jini da juriya suna ƙaruwa yayin da adadin magani yake ƙaruwa, tare da damuwa game da raguwar isar jini ga gabobin cikin ciki a 7 mg/kg.
Jadawalin gwaje-gwaje
IV na nufin ta jijiya. NE na nufin norepinephrine. MAP na nufin matsakaicin matsin jini a jijiyoyin arteri. SVR na nufin juriyar jijiyoyin jini a dukkan jiki. Kowane layi yana nuna abin da aka ba mahalarta a bincike, ba shawarar magani ba.
| Gwaji da yanayi | Tsarin bayar da magani | Sakamako kan magungunan ƙara matsin jini | Sakamako kan zagayawar jini | Mace-mace | Illoli |
|---|---|---|---|---|---|
| Levin 2004: vasoplegia da ta riga ta faru bayan tiyatar zuciya, 28 idan aka kwatanta da 28 | 1.5 mg/kg IV a tsawon awa 1 | Vasoplegia ta gushe a duk marasa lafiyar da suka karɓi maganin cikin awa 6; 8 daga cikin 28 na rukunin kwatanci sun ci gaba da ita bayan awa 48 | MAP da SVR sun dawo da sauri a rukunin da ya karɓi maganin | 0 daga cikin 28 idan aka kwatanta da 6 daga cikin 28; gwajin ya yi ƙanƙanta sosai don tabbatar da tasiri kan tsira | Ba a bayar da rahoton wata babbar alamar guba da wannan tsarin ba |
| Ozal 2005: rigakafi a marasa lafiya 100 masu babban haɗari da aka yi wa tiyatar samar da sabuwar hanyar jini ga zuciya, 50 idan aka kwatanta da 50 | Ruwan magani na 1 percent da aka fara bayarwa ta jijiya awa 1 kafin tiyata | Vasoplegia 0 daga cikin 50 idan aka kwatanta da 13 daga cikin 50; rigakafi ne, ba magance wadda ta riga ta faru ba | Matsin jini ya fi girma yayin tiyata a rukunin da ya karɓi maganin | Ba gwajin mace-mace ba ne | Ba a bayar da rahoton wata babbar alamar guba ba |
| Cho: methylene blue na rigakafi a tiyatar zuciya | Bayarwa ta jijiya a lokacin da ke kewaye da tiyata | Babu bambanci mai muhimmanci a ƙididdiga game da magungunan ƙara matsin jini | MAP da SVR ba su bambanta da muhimmanci a ƙididdiga ba | Ba gwajin mace-mace ba ne | Ba a bayar da takamaiman rahoton yawan faruwar illoli ba |
| Kirov 2001: gwajin farko na shok na sepsis, 10 idan aka kwatanta da 10 | 2 mg/kg lokaci guda da sauri, sannan bayarwa ta jijiya da ƙarin adadi mataki-mataki har jimilla ta kai 5.75 mg/kg | NE ya ragu har zuwa 87 percent; epinephrine ya ragu 81 percent; dopamine ya ragu 40 percent | MAP ya fi girma da muhimmanci a ƙididdiga a awa 6 da 24 | Mace-mace cikin kwanaki 28 sun kasance 5 daga cikin 10 idan aka kwatanta da 7 daga cikin 10; ba gwajin mace-mace ba ne | Fitsari mai shuɗi da sauyin launin fata; babu babbar alamar guba ga gabobi |
| Memis 2002: sepsis mai tsanani, 15 idan aka kwatanta da 15 | 0.5 mg/kg a kowace awa na tsawon awa 6 | Babu ma'aunin ƙididdiga na rage buƙatar magungunan ƙara matsin jini | MAP bayan bayar da maganin ta jijiya ya kasance 85 idan aka kwatanta da 74 mmHg | Ba shi da isasshen ƙarfin ƙididdiga don tantance mace-mace | Ba a bayar da rahoton wata babbar alamar guba ba |
| Ibarra-Estrada 2023: shok na sepsis, an nazarci 91 | Bayarwa ta jijiya na tsawon awa shida kullum, har sau uku | Lokacin tsakiyar rarraba bayanai har zuwa daina magungunan ƙara matsin jini ya kasance awa 69 idan aka kwatanta da 94 | An sarrafa matsin jini zuwa matakin da aka sa a gaba a rukunan biyu | Mace-mace sun yi kama tsakanin rukunan | Fitsari mai shuɗi ko kore ya yawaita; an ware masu ƙarancin G6PD da waɗanda suka yi amfani da SSRI kwanan nan |
| Dong 2025: shok na sepsis tare da amfani da na'urar taimakon numfashi, 36 idan aka kwatanta da 36 | 2 mg/kg a tsawon mintuna 15 tare da 1 mg/kg a tsawon awa 12 | Bambancin NE ya kusanci sifili; babu bambanci a lokacin har zuwa daina magungunan ƙara matsin jini | Bambancin MAP ya kasance debe 1.2 mmHg, ba shi da muhimmanci a ƙididdiga; gudanawar jini a ƙananan jijiyoyi ta inganta | Mace-mace cikin kwanaki 28 sun kasance 9 daga cikin 36 idan aka kwatanta da 15 daga cikin 36, ba bambanci mai muhimmanci a ƙididdiga ba | Fitsari mai shuɗi ko kore a duk marasa lafiyar da suka karɓi maganin; babu alamar matsala ta hanta, ƙoda, ko isar oxygen |
Shin wani daga cikin waɗannan ya nuna raguwar mace-mace?
Nazarin da ya haɗa sakamakon gwaje-gwaje ya nuna sakamako mafi kyau fiye da na kowane gwaji shi kaɗai, amma waɗannan ƙididdiga masu kyau suna raunana idan aka bincike su sosai. Wani nazarin haɗa sakamakon gwaje-gwajen shok na sepsis shida na 2024 ya gano rabon haɗarin mace-mace na ɗan gajeren lokaci ya kasance 0.66, amma tasirin ya rasa muhimmancinsa a ƙididdiga bayan an cire gwaje-gwajen da ke da babban haɗarin karkatar sakamako. Nazarin haɗa sakamako na baya-bayan nan wanda ya ƙunshi gwaje-gwajen RCT kawai, wato gwaje-gwajen da ake raba mahalarta bisa bazuwar zaɓi tare da rukunin kwatanci, ya haɗa gwaje-gwaje tara da marasa lafiya 535. Ya gano rabon yiwuwar mace-mace cikin kwanaki 28 zuwa 30 ya kasance 0.73, tare da tazarar amincewa daga 0.40 zuwa 1.36, wanda ba shi da muhimmanci a ƙididdiga. Nazarin jere na gwaje-gwajensa kuma ya ƙiyasta cewa za a buƙaci marasa lafiya 1,773, maimakon ɗaruruwa kaɗan da ake da su. Takaitawa ta gaskiya ita ce ba a tabbatar da fa'idar ƙara tsira ba, ba wai an tabbatar da rashin wannan fa'idar ba.
Bayanan tsaro daga shaidun asibiti
Abubuwan da aka saba gani a gwaje-gwajen sun kasance fitsari mai shuɗi ko kore da sauyin launin fata, tare da ɗan ƙaruwar methemoglobin. Bayanin haɗurra masu tsanani ya fito daga bayanin samfurin da aka ba lasisin bayarwa ta jijiya, maimakon daga ƙididdigar abubuwan da suka faru a gwaje-gwajen: ciwon serotonin idan an haɗa shi da magungunan da ke shafar serotonin ko opioids; hana amfani da shi ga masu ƙarancin G6PD saboda haɗarin lalacewar jajayen ƙwayoyin jini; karatun na'urar auna oxygen ta bugun jini da ke nuna ƙasa da ainihin mataki yayin bayar da maganin ta jijiya da ɗan lokaci bayan haka; da hawan jini a matsayin illar da aka bayar da rahoto. Gwaje-gwajen zamani da dama sun ware marasa lafiya masu ƙarancin G6PD ko waɗanda suka yi amfani da magungunan da ke shafar serotonin kwanan nan, don haka jadawalin tsaronsu da bai nuna matsaloli ba bai auna haɗarin waɗannan rukunan ba. Ya kamata a karanta wannan shaidar tare da bayani na gaba ɗaya kan amfani a asibiti da kuma tantance tsaro; masu karatu da ba su saba da tsarin gwaje-gwaje ba za su iya fara da jagorar karanta binciken methylene blue.
Vasoplegia da shok na sepsis na iya buƙatar zurfafaffen bita dabam-dabam idan shaidun suka ƙaru, amma binciken da ake da shi yanzu ya dace da bita guda ta kulawa da marasa lafiya masu tsanani: akwai ainihin tasirin ƙuntata jijiyoyin jini da rage buƙatar magungunan ƙara matsin jini, wanda ya fi bayyana a vasoplegia da ta riga ta faru da shok na sepsis na farkon lokaci, ba tare da nuna ƙarin tsira ba, kuma tare da iyakokin tsaro da suka ware wasu rukunan marasa lafiya. Duk wanda yake cikin waɗannan yanayi ya riga ya kasance ƙarƙashin kulawa ta musamman, kuma amfani da methylene blue a wannan yanayin shawarar ƙungiyar masu kula da mara lafiya ce a sashen ICU, ba maganin gida da aka samo daga abin da ake bayarwa ta jijiya a asibiti ba.