Nkhani
Methylene blue pochiza methemoglobinemia: chifukwa chake imagwiritsidwa ntchito m'zipatala
Wodwala akufika ali ndi milomo yotuwa ngati mwala wa slate, akupuma mofulumira, ndipo akuyankha mochedwa. Chipangizo choyang'anira chikusonyeza kuti kuchuluka kwa hemoglobini yomangirira okosijeni ndi 85 peresenti. Namwino akuwonjezera okosijeni. Chiwerengerocho sichikusintha. Magazi akutengedwa ndipo akutuluka ali abulauni ngati chokoleti, ndipo akukhalabe abulauni akakhala poyera. Zimenezi ndi zizindikiro zomwe nthawi zambiri zimayambitsa chisamaliro cha methemoglobinemia pogwiritsa ntchito methylene blue, ndipo zimasonyeza chifukwa chake vutoli limasokoneza mabanja komanso zipangizo.
Vuto silili m'mapapo. Lili pa ayironi yomwe ili mkati mwa hemoglobini.
Mitundu iwiri ya atomu yomweyo ya ayironi
Molekyulu iliyonse ya hemoglobini ili ndi ayironi ya mtundu wa ferrous, yolembedwa Fe2+. Ikakhala ya mtundu umenewu, imamanga okosijeni m'mapapo n'kuutulutsa m'minofu ya thupi. Mankhwala ochititsa oxidation angachotse elekitironi inanso pa ayironi imeneyo, n'kuisintha kukhala ya mtundu wa ferric, Fe3+. Chinthu chopereka mtundu chomwe chimapangidwa ndi methemoglobini. Ayironi ya ferric singamange okosijeni, ndipo choipa kwambiri n'chakuti imapangitsa malo otsala a ferrous m’molekyulu yomweyo kugwira okosijeni wawo mwamphamvu kwambiri, motero okosijeni wochepa amatulutsidwa kumene akufunika.
Magazi athanzi amasunga methemoglobini pansi pa pafupifupi 1 peresenti chifukwa enzayimu yokonza imagwira ntchito nthawi zonse. Njira yaikulu yokonza imagwiritsa ntchito NADH ndi cytochrome b5 reductase, ndipo imathandizidwa ndi glycolysis yachizolowezi m'selo lofiira la magazi. Njira yothandizira imagwiritsa ntchito NADPH, koma nthawi zambiri imagwira ntchito yochepa. Zizindikiro zimayenderana pafupifupi ndi kuchuluka kwa methemoglobini, ngakhale kuchepa kwa magazi kapena matenda a mtima ndi mapapo kungapangitse kuti ngakhale kuchuluka kochepa kukhale koopsa. Kuchuluka koyandikira 10 mpaka 20 peresenti kungayambitse khungu kuoneka labuluu ndi kutopa. Kuchuluka kopitirira 30 peresenti nthawi zambiri kumayambitsa mutu, kupuma movutikira, ndi kusokonezeka maganizo. Kuchuluka koyandikira 70 peresenti nthawi zambiri kumapha. Ziwerengerozi ndi magulu oyerekezera, osati zotsimikizira zimene zidzachitike, chifukwa chofunika ndi kufika kwa okosijeni m'minofu, osati chiwerengero cha ku labotale chokha.
Zinthu zofala zoyambitsa vutoli zomwe munthu amakumana nazo ndi dapsone, nitrites ndi nitrates, zinthu za aniline, komanso mankhwala ogonetsa ululu pamalo ena monga benzocaine ndi prilocaine. Kuperewera kwa maenzayimu kobadwa nako kulipo koma n'kosowa. Anthu ambiri amene amachizidwa m'chipatala amakhala ndi vutoli chifukwa cha zinthu zomwe anakumana nazo, kutanthauza kuti sitepe yoyamba ya chithandizo nthawi zonse ndi kusiya kukhudzidwa ndi chinthu choyambitsacho.
Njira yosamutsa yomwe zipatala zimagwiritsa ntchito
Methylene blue sipereka okosijeni. Imapereka njira yonyamulira maelekitironi. Mkati mwa selo lofiira la magazi, enzayimu imagwiritsa ntchito NADPH kusandutsa utoto wabuluuwo kukhala mtundu wake wopanda mtundu, leucomethylene blue. Kenako mtundu wopanda mtunduwo umapereka maelekitironi ku ayironi ya ferric popanda kugwiritsa ntchito enzayimu, n'kubwezeretsa hemoglobini ya ferrous, ndipo umabwerera ku mtundu wabuluu. Utotowo umagwira ntchito mobwerezabwereza. Kusinthana kumeneku kumafotokozedwa pa mmene methylene blue imasunthira maelekitironi pakati pa opereka ndi olandira, ndipo mtundu wopanda mtundu womwe walandira maelekitironi ukufotokozedwa mu kuyerekezera methylene blue ndi leucomethylene blue.
Njira imeneyi ikufotokoza malire awiri amene amadabwitsa anthu atsopano pa nkhaniyi. Choyamba, njira yosamutsayi imafuna NADPH, ndipo NADPH ya m'selo lofiira la magazi imadalira glucose-6-phosphate dehydrogenase, G6PD. Pakakhala kuperewera kwa G6PD, utotowo ungalephere kusanduka mtundu wake wogwira ntchito, uku ukuwonjezera kuvutitsidwa kwa selo chifukwa cha oxidation yake yokha. N'chifukwa chake malangizo a mankhwala a m'chipatala amatchula kuperewera kwa G6PD ngati chifukwa choletsa kugwiritsa ntchito mankhwalawo. Chachiwiri, methylene blue yokha imakhala chinthu chochititsa oxidation pamene milingo yonse yoperekedwa ikakhala yambiri. Mlingo wonse ukapitirira pafupifupi 7 mg pa kg, kapena nthawi zina kucheperapo ngati waperekedwa mobwerezabwereza, ungawonjezere methemoglobini ndi kuwononga maselo ofiira a magazi m'malo mowakonza. Utoto wochuluka sutanthauza kupulumutsa kwambiri. Malire a mlingo ndi ochepa mwadala.
Chifukwa chake mayeso odziwika bwino amasokeretsa
Mabanja nthawi zambiri amafufuza mayeso a methylene blue omwe angachite kunyumba. Palibe mayeso oterowo. Mawu amenewa nthawi zambiri amatanthauza kufufuza kozindikira methemoglobinemia yomwe ikuganiziridwa, ndipo kufufuza kumeneku kuyenera kuchitika ku labotale.
Zipangizo zachizolowezi za pulse oximeter zimawerenga mafunde a kuwala a utali uwiri wokha. Methemoglobini ikachuluka, kuyamwa kwa kuwala pa utali wa mafunde awiriwo kumayandikirana, ndipo kuchuluka kosonyezedwa kumayandikira pafupifupi 85 peresenti mosasamala za mmene zinthu zililidi. Kuwonjezera okosijeni sikukonza chiwerengerocho chifukwa sensayo sikuyeza chomwe chili cholakwika. Panthawi imodzimodziyo, kuthamanga kwa okosijeni m'magazi a m'mitsempha yochokera ku mtima, PaO2, kungawoneke kwabwinobwino, chifukwa kumayeza okosijeni wosungunuka m'madzi a m'magazi, osati okosijeni wonyamulidwa ndi hemoglobini. Choncho chipangizo chowunika mpweya wa m'magazi chomwe chimawerengera kuchuluka kwa hemoglobini yomangirira okosijeni kuchokera pa PaO2 chingapereke chiwerengero cholimbikitsa pamene wodwalayo akukhalabe ndi khungu labuluu. Kusiyana pakati pa chiwerengero cha sensa ya pa chala ndi chiwerengero chowerengedwa cha magazi a m'mitsempha yochokera ku mtima, komwe nthawi zambiri kumaposa mfundo 5 za peresenti, kumatchedwa kusiyana kwa saturation. Ndi chizindikiro chothandiza kufufuza, osati kutsimikizira matenda.
Kutsimikizira kumafuna co-oximetry yogwiritsa ntchito mafunde a kuwala a utali wosiyanasiyana pa magazi otengedwa, yomwe imayeza methemoglobini mwachindunji. Magazi abulauni ngati chokoleti omwe sasintha kukhala owala akapatsidwa okosijeni amasonyezanso vutoli. Chisankho chilichonse cha chithandizo cha methemoglobinemia chimayambira pa muyeso umenewo limodzi ndi zizindikiro, osati pa pulse oximeter yokha.
Mmene chithandizo choyang'aniridwa chafotokozedwera m'malangizo a mankhwala
Gawoli likufotokoza jakisoni woperekedwa ndi ogwira ntchito zachipatala motsatira chilolezo cha mankhwala. Si malangizo a kugwiritsa ntchito pakamwa, ndipo mfundo zonsezi sizikukhudza madontho kapena makapisozi ogulitsidwa kuti anthu azigwiritsa ntchito paokha.
Malangizo amakono operekera jakisoni wa methylene blue amafotokoza kuti chithandizo cha methemoglobinemia yoyambitsidwa ndi zinthu zomwe munthu wakumana nazo, kwa akuluakulu ndi ana, ndi 1 mg pa kg yoperekedwa kudzera mumtsempha kwa mphindi 5 mpaka 30. Pogwiritsa ntchito mankhwala achizolowezi a 5 mg pa mL, zimenezi ndi 0.2 mL pa kg. Ngati methemoglobini ikadali pamwamba pa 30 peresenti kapena zizindikiro zikupitirirabe patatha ola limodzi, mlingo wachiwiri wa 1 mg pa kg ungaperekedwe. Ngati milingo iwiri siithetsa vutoli, malangizowo amauza ogwira ntchito zachipatala kuti agwiritse ntchito chithandizo china m'malo mwa mlingo wachitatu.
Mfundo za mmene mankhwalawo amaperekedwera ndi zofunika. Chubu choperekera chiyenera kukhala cholowera mumtsempha chogwira ntchito bwino, osati jakisoni wa pansi pa khungu. Mankhwala amadziwo angachepetsedwe mphamvu posakanizidwa mu 50 mL ya dextrose ya 5 peresenti kuti achepetse ululu pamalo operekera, makamaka kwa ana, ndipo agwiritsidwe ntchito msanga. Sayenera kuchepetsedwa mphamvu posakanizidwa ndi madzi a sodium chloride, chifukwa chloride imachepetsa kuthekera kwa utotowo kusungunuka. Zotsala zosagwiritsidwa ntchito zimatayidwa, ndipo mankhwala amadziwo amawunikidwa asanagwiritsidwe ntchito.
Machenjezo atatu amatsogolera chisankho chilichonse cha m'chipatala. Chenjezo lomwe lili m'bokosi limakhudza serotonin syndrome, yomwe ingaphe pamene methylene blue yagwiritsidwa ntchito limodzi ndi mankhwala okhudza serotonin, kuphatikizapo SSRIs, SNRIs, MAO inhibitors, ma opioid ena, ndi dextromethorphan. Odwala amauzidwa kuti asamamwe mankhwala oterowo kwa maola 72 pambuyo pa mlingo womaliza. Ngati kugwiritsa ntchito limodzi sikungapeweke, malangizowo amafuna mlingo wochepa kwambiri wotheka komanso kuyang'aniridwa mosamala. Kugwirizana kwa mankhwala okhudza serotonin kukufotokozedwa mu kugwirizana kwa methylene blue ndi mankhwala ena komanso serotonin syndrome. Hemolysis ndi chenjezo lachiwiri: kuwonongeka kwa maselo ofiira a magazi kokhala ndi Heinz bodies, kuwonjezeka kwa indirect bilirubin, kuchepa kwa haptoglobin, ndi kuchepa kwa magazi komwe kungayambe patatha tsiku limodzi kapena kupitirira ndipo kungafune kuikidwa magazi. Chenjezo lachitatu ndi kulephera kugwira ntchito kapena kubwereranso kwa vutoli, komwe kumaoneka pambuyo pokhudzidwa ndi dapsone kapena zinthu zamtundu wa aniline komanso pakuperewera kwa G6PD; pamenepa malangizowo amalozeranso ku chithandizo china. Kulephera kwa impso kugwira ntchito bwino sikuletsa kugwiritsa ntchito mankhwalawa, koma ngati kulepherako kuli kwapakati mpaka kwakukulu, chithandizocho chimangokhala mlingo umodzi wa 1 mg pa kg. Zotsatira zosafunika zomwe zinalembedwa mu deta ya akuluakulu m'malangizo a mankhwalawo zinaphatikizapo mutu, nseru, kutsekula m'mimba, kuchepa kwa potaziyamu ndi maginiziyamu, kunjenjemera kwadzidzidzi kwa minofu, ndi zochitika ngati kugwidwa ndi khunyu, ndipo panali chochitika chimodzi choopsa ngati kugwidwa ndi khunyu mwa odwala 31. Utotowo umachepetsanso molakwika ziwerengero za pulse oximeter pambuyo poperekedwa kudzera mumtsempha, choncho ogwira ntchito zachipatala amatsatira co-oximetry ndi zizindikiro m'malo mwake.
Chisamaliro chothandizira chimaperekedwa nthawi yomweyo: okosijeni woyenda kwambiri, kuthandiza njira ya mpweya ndi kayendedwe ka magazi, kukonza mulingo wa glucose, ndi kuyang'anira. Matenda opepuka opanda zizindikiro angathe kutha chinthu choyambitsacho chikachotsedwa. Malire otchulidwa kawirikawiri amalimbikitsa kuchiza odwala omwe ali ndi zizindikiro kuyambira pafupifupi 20 peresenti, kapena kuchokera pa 10 mpaka 20 peresenti ngati kufika kwa okosijeni m'minofu kwasokonekera kale, komanso kuganizira chithandizo kwa odwala opanda zizindikiro kuyambira pafupifupi 30 peresenti. Zizindikiro zoopsa zimachizidwa popanda kudikira chiwerengero cha ku labotale. Ascorbic acid, kusinthitsa magazi poika ena, ndi okosijeni woperekedwa pa kuthamanga kwakukulu ndi njira zopulumutsira pamene methylene blue singagwiritsidwe ntchito kapena yalephera, koma ascorbic acid imagwira ntchito pang'onopang'ono kwambiri. Zikalata zotsimikizira kuyera kwa mankhwala aliwonse a jakisoni ndi nkhani ina ya kupanga mankhwala, yofotokozedwa mu mmene mungawerengere satifiketi ya kusanthula methylene blue.
Benzocaine ndi funso la gel ya kutuluka mano
Kufufuza kochuluka kwa anthu kumachokera kwa makolo amene agwiritsa ntchito gel kapena mankhwala opopera pakamwa okhala ndi benzocaine, kenako n'kuona milomo yabuluu kapena chiwerengero chochepa pa oximeter. Magawo atatu ayenera kusiyanitsidwa.
Kukayikira kuti mwana wakhudzidwa ndi mankhwalawa ndi gawo la kunyumba. Benzocaine imadziwika kuti ndi chinthu chochititsa oxidation chomwe chimayambitsa vutoli, ndipo oyang'anira mankhwala achenjeza kuti mankhwala a benzocaine ogwiritsidwa ntchito pakamwa omwe amagulitsidwa popanda chilolezo cha dokotala sayenera kugwiritsidwa ntchito pa kutuluka mano kapena kwa ana osakwana zaka 2. Izi n'chifukwa chakuti methemoglobinemia yokhudzana ndi benzocaine ingakhale yoopsa, ndipo phindu lake pochepetsa ululu wa kutuluka mano ndi laling'ono. Siyani kugwiritsa ntchito mankhwalawo, lembani nthawi ndi kuchuluka kwake, lembani zizindikiro monga kutuwa kosazolowereka, mtundu wotuwa kapena wabuluu wa milomo ndi malo a pansi pa zikhadabo, kupuma movutikira, kugona kosazolowereka, kapena kudya movutikira, ndipo pezani kuunikidwa mwadzidzidzi kuchipatala msanga. Musapereke methylene blue kunyumba m'njira iliyonse. Palibe mlingo wa kunyumba komanso palibe mayeso a kunyumba amene angatsimikizire kuti vutoli kulibe.
Kuzindikira matendawa ndi gawo la m'chipatala. Ogwira ntchito zachipatala amatsimikizira ndi co-oximetry, amawunika zinthu zonse zochititsa oxidation zomwe wodwalayo wakumana nazo, kuphatikizapo dapsone, nitrites, ndi zinthu za aniline, ndipo amaunika zizindikiro ndi kufika kwa okosijeni m'minofu m'malo mongoyang'ana chiwerengero chimodzi chokha.
Chithandizo choyang'aniridwa ndi gawo la m'chipinda cha odwala lofotokozedwa pamwambapa. Kaya benzocaine ndi yomwe inayambitsa vutoli kapena ayi, zimenezi sizisintha tebulo la milingo. Malangizo amakono a jakisoni satchula benzocaine mwapadera; vuto loyambitsidwa ndi benzocaine limawerengedwa ngati methemoglobinemia yoyambitsidwa ndi zinthu zomwe munthu wakumana nazo, ndipo limasamalidwa potsatira ndondomeko yomweyo yoyang'aniridwa, kuphatikizapo kuunika G6PD, impso, ndi mankhwala okhudza serotonin.
Pamene methylene blue si yankho
Si yankho ngati kuperewera kwa G6PD kwadziwika. Si yankho pambuyo poti milingo iwiri yofotokozedwa m'malangizo yalephera, kapena pamene methemoglobinemia yabwereranso, zomwe zimasonyeza kuti mankhwala monga dapsone akupitirirabe kulowa m'thupi. Si yankho ngati njira yopewera, ngati chinthu chowonjezera chogwiritsidwa ntchito nthawi zonse, kapena ngati chithandizo cha kunyumba pambuyo pokhudzidwa ndi mankhwala ena. Mlingo waukulu kapena kugwiritsa ntchito mobwerezabwereza kungawonjezere chiwerengero chomwe mankhwalawo cholinga chake ndi kuchichepetsa, ndipo hemolysis ingaonekere patatha tsiku limodzi pamene wodwalayo wabwerera kale kunyumba. Chiopsezo chochedwa chimenechi ndi chimodzi mwa zifukwa zomwe zipatala zimayang'anira odwala m'malo mowatulutsa msanga.
Chidule chowona ndi chachifupi. Methemoglobinemia ndi vuto la ayironi yomwe yachitika oxidation ndipo singanyamule okosijeni. Methylene blue ndi njira yosamutsa maelekitironi yomwe imalola maselo ofiira a magazi kubwezeretsa ayironi imeneyo polandira maelekitironi, ngati seloyo ingapange NADPH komanso ngati mlingowo ukhala mkati mwa malire ochepa a chithandizo ofotokozedwa m'malangizo. Kuzindikira matendawa kumafuna co-oximetry chifukwa zipangizo zosavuta zoyang'anira zimasokeretsa. Zina zonse, kuyambira pa dextrose yochepetsera mphamvu ya mankhwala mpaka mbiri ya mankhwala okhudza serotonin ndi chubu cha benzocaine m'kabati ya mankhwala, ndi mfundo zothandizira njira imodzi yosamutsayi.