Inyandiko
Ubururu bwa metilene kuri vasoplegia na shoki iterwa n'ubwandu: icyo igerageza ku barwayi rigaragaza
Umurwayi ava mu cyumba cyo kubagiramo nyuma yo kubagwa umutima, umutima we wohereza amaraso ku gipimo gisanzwe ariko umuvuduko w'amaraso ntubashe kuguma ku rwego rukenewe. Ku kindi gitanda, umurwayi ufite ubwandu bukomeye akenera ingano za norepinephrine zigenda ziyongera kugira ngo umuvuduko ugume hejuru y'urwego rwifuzwa. Izo ngero zombi zirimo imiyoboro y'amaraso yatakaje ubushobozi bwo kwikanya, kandi zombi zatumye abaganga bita ku barwayi barembye bagerageza ubururu bwa metilene. Iyi nyandiko isesengura ibyageragejwe koko mu igerageza ku barwayi n'ibyagaragaye.
Hari ibintu bibiri bigomba gutandukanywa muri byose bikurikira. Icya mbere, vasoplegia nyuma yo kubagwa umutima na shoki iterwa n'ubwandu ni indwara zitandukanye zifite igerageza ryateguwe mu buryo butandukanye, bityo buri imwe ikaba ifite igice cyayo. Icya kabiri, gukenera imiti mike izamura umuvuduko w'amaraso si kimwe no kugira amahirwe menshi yo kurokoka. Igerageza ryinshi ryapimye icya mbere; hafi nta na rimwe ryari rinini bihagije kugira ngo ritange umwanzuro ku cya kabiri.
Impamvu ubururu bwa metilene bushobora kongera ubushobozi bw'imiyoboro y'amaraso bwo kwikanya
Imiyoboro y'amaraso ava mu mutima iragabanuka kandi ikaguka uko imikaya yayo yorohereye yikanya cyangwa ikadohoka, kandi ubugari bwayo bugena igice kinini cy'uburwanya itembera ry'amaraso mu mubiri. Kimwe mu bimenyetso bituma iyo mikaya idohoka gituruka kuri nitric oxide, kikanyura kuri guanylate cyclase ishonga, kikagera kuri GMP y'umuzenguruko, iteza ukudohoka. Ubururu bwa metilene bubangamira iyo nzira, ari na byo bituma bushobora kurwanya ukwaguka gukabije kw'imiyoboro y'amaraso muri shoki. Uburyo bukora mu mubiri ntibugarukira ku guhagarika intambwe imwe gusa: mu igerageza ryerekeye ikorwa rya nitric oxide no kudohoka kw'imiyoboro y'amaraso, ubururu bwa metilene bwagize icyo bukora ku ntambwe zirenze imwe muri uru ruhererekane rw'ibimenyetso. Ubwo bushakashatsi busobanura uburyo bushoboka bwo gukora. Ntibuhanura uko umuvuduko w'amaraso w'umurwayi runaka uzahinduka.
Igerageza ryose rikurikira ryakoresheje ubururu bwa metilene butangwa mu mutsi mu bitaro, bwiyongera ku buvuzi busanzwe bw'abarembye. Nta na kimwe hano kigerageza igicuruzwa kinyobwa mu rugo.
Vasoplegia nyuma yo kubagwa umutima
Vasoplegia hano ni igabanuka rikabije ry'ubushobozi bw'imiyoboro y'amaraso bwo kwikanya nyuma yo gukoresha imashini isimbura umurimo w'umutima n'ibihaha: umuvuduko n'uburwanya itembera ry'amaraso biba biri hasi nubwo ingano y'amaraso umutima wohereza iba ikiri nziza. Ibimenyetso biva mu igerageza rigabanya abarwayi mu matsinda ku buryo bwa tombola ku kuvura vasoplegia yamaze kubaho bishingiye ahanini ku igerageza rimwe rito. Andi magerageza abiri yagerageje ubururu bwa metilene mbere cyangwa mu gihe cyo kubaga kugira ngo akumire vasoplegia, kikaba ari ikindi kibazo cy'ubuvuzi.
Mu igerageza rya Levin na bagenzi be ryagabanyije abarwayi bafite vasoplegia yamaze kubaho nyuma yo kubagwa mu matsinda ku buryo bwa tombola, abarwayi 56 bahawe 1.5 mg/kg itangwa buhoro mu mutsi mu gihe cy'isaha imwe cyangwa bahabwa umuti usa n'uwo ariko udafite ikinyabutabire gikora. Vasoplegia yashize vuba mu itsinda ryahawe ubururu bwa metilene, mu gihe 8 muri 28 bahawe umuti udafite ikinyabutabire gikora bakomeje kuyigira nyuma y'amasaha 48, kandi impfu zari 0 muri 28 ugereranyije na 6 muri 28. Kuba shoki yarashize biragaragara cyane, ariko abarwayi 56 ntibahagije kugira ngo bemeze ingaruka ku kurokoka, kandi itandukaniro ry'impfu ntirihamye bihagije ngo rifatwe nk'irikoreshwa ku barwayi bose.
Igerageza ryo gukumira ryatanze ibisubizo bitandukanye. Mu bushakashatsi bwa Ozal na bagenzi be ku barwayi bafite ibyago byinshi babazwe kugira ngo amaraso anyuzwe ahandi hatari mu miyoboro y'umutima yafunze, gutanga ubururu bwa metilene buhoro mu mutsi mbere yo kubagwa byagabanyije vasoplegia, iva kuri 13 muri 50 igera kuri 0 muri 50. Maslow na bagenzi be babonye ingaruka zamaze igihe gito mu gihe cyo kubaga hakoreshejwe imashini isimbura umutima n'ibihaha, naho Cho na bagenzi be hafi nta nyungu babonye ku itembera ry'amaraso cyangwa ku miti izamura umuvuduko w'amaraso. Gukumira ku barwayi batoranyijwe babagwa no gutabara abafite vasoplegia yamaze kubaho bigomba gufatwa nk'ibivugwa bitandukanye bifite ibimenyetso bitandukanye.
Shoki iterwa n'ubwandu
Shoki iterwa n'ubwandu ihuza ubwandu n'ikudakora neza kw'itembera ry'amaraso gukomeza nubwo umurwayi yahawe amazi mu mutsi. Bityo norepinephrine iba ishingiro ry'ubuvuzi, kandi igerageza rishaka kumenya niba ubururu bwa metilene bugabanya igihe catecholamines zikoreshwa. Ibyagaragaye birahuye kurusha mu kubaga, ariko biracyatandukanye, kandi bireba kugabanya imiti izamura umuvuduko w'amaraso aho kuba kurokoka.
Igerageza rinini kurusha ayandi yo mu bihe bya vuba ni ubushakashatsi bwa Ibarra-Estrada na bagenzi be bwo mu 2023 bwagabanyije abarwayi mu matsinda ku buryo bwa tombola, bukongera ubururu bwa metilene hakiri kare ku buvuzi busanzwe. Abantu bakuru 91 basesenguwe bahawe ubururu bwa metilene buhoro mu mutsi mu gihe cy'amasaha atandatu buri munsi, inshuro eshatu, cyangwa umuti usa na bwo udafite ikinyabutabire gikora. Ibyo byiyongeraga kuri norepinephrine, hydrocortisone na vasopressin igihe byari bikenewe. Igihe cyo guhagarika imiti izamura umuvuduko w'amaraso cyari gifite agaciro ko hagati k'amasaha 69 ugereranyije n'amasaha 94, naho impfu n'igihe cyo gufashwa guhumeka bikaba bisa. Igerageza ryabanje ryari rito: igerageza ry'ibanze rya Kirov na bagenzi be ku barwayi 20 ryagaragaje igabanuka rikomeye rya catecholamines nyuma ya 2 mg/kg itanzwe icyarimwe mu mutsi, igakurikirwa n'ingano zigenda ziyongera zitangwa buhoro mu mutsi. Memis na bagenzi be babonye umuvuduko mpuzandengo w'amaraso mu miyoboro ava mu mutima uri hejuru nyuma yo gutanga umuti (85 ugereranyije na 74 mmHg), ariko nta gipimo cyateganyijwe cyo kugabanya imiti izamura umuvuduko w'amaraso. Bitandukanye n'ibyo, igerageza rya Dong na bagenzi be ku barwayi 72, ryagereranyaga ubururu bwa metilene n'umuti udafite ikinyabutabire gikora, nta nyungu ifatika ryabonye kuri norepinephrine cyangwa ku muvuduko. Irindi gereranya ryasanze vasopressin iruta ubururu bwa metilene nk'umuti wa kabiri uzamura umuvuduko w'amaraso ku masaha 12 na 24. Ubushakashatsi bwo kumenya ingano iboneye bwakozwe na Juffermans na bagenzi be bwagaragaje ko umuvuduko n'uburwanya itembera ry'amaraso byiyongeraga uko ingano yiyongeraga, ariko kugabanuka kw'amaraso agera ku ngingo zo mu nda bikaba impungenge kuri 7 mg/kg.
Imbonerahamwe y'igerageza
IV bivuga gutanga mu mutsi. NE bivuga norepinephrine. MAP bivuga umuvuduko mpuzandengo w'amaraso mu miyoboro ava mu mutima. SVR bivuga uburwanya itembera ry'amaraso mu miyoboro yo mu mubiri. Buri murongo ugaragaza ibyahawe abarwayi mu bushakashatsi, ntabwo ari inama y'ubuvuzi.
| Igerageza n'aho ryakorewe | Uburyo bwo gutanga | Ibyagaragaye ku miti izamura umuvuduko w'amaraso | Ibyagaragaye ku itembera ry'amaraso | Impfu | Ingaruka mbi |
|---|---|---|---|---|---|
| Levin 2004: vasoplegia yamaze kubaho nyuma yo kubagwa umutima, 28 ugereranyije na 28 | 1.5 mg/kg IV mu gihe cy'isaha 1 | Vasoplegia yashize ku barwayi bose bahawe umuti mu masaha 6; 8 muri 28 bo mu itsinda ryo kugereranya bakomeje kuyigira nyuma y'amasaha 48 | MAP na SVR byagarutse vuba ku rwego rwiza mu itsinda ryahawe umuti | 0 muri 28 ugereranyije na 6 muri 28; umubare ni muto cyane ku buryo utakwemeza ingaruka ku kurokoka | Nta kimenyetso cy'uburozi bukomeye cyatangajwe kuri ubu buryo bwo gutanga |
| Ozal 2005: gukumira ku barwayi 100 bafite ibyago byinshi babazwe hakoreshejwe imashini isimbura umutima n'ibihaha, 50 ugereranyije na 50 | Umuti ushongeshejwe ku gipimo cya 1 ku ijana, utangwa buhoro mu mutsi guhera isaha 1 mbere yo kubagwa | Vasoplegia 0 muri 50 ugereranyije na 13 muri 50; gukumira, si ugutabara | Umuvuduko wari hejuru mu gihe cyo kubaga mu itsinda ryahawe umuti | Ntabwo ryari igerageza rigamije gupima impfu | Nta kimenyetso cy'uburozi bukomeye cyatangajwe |
| Cho: ubururu bwa metilene bwo gukumira mu kubaga umutima | Gutanga buhoro mu mutsi mu gihe gikikije kubagwa | Nta tandukaniro rifite ubusobanuro bw'ibarurishamibare ku miti izamura umuvuduko w'amaraso | MAP na SVR ntibyagize itandukaniro rifite ubusobanuro bw'ibarurishamibare | Ntabwo ryari igerageza rigamije gupima impfu | Nta gipimo cyihariye cy'ingaruka mbi cyatangajwe |
| Kirov 2001: igerageza ry'ibanze kuri shoki iterwa n'ubwandu, 10 ugereranyije na 10 | 2 mg/kg itanzwe icyarimwe, ikurikirwa no gutanga buhoro mu mutsi mu byiciro kugeza ku giteranyo cya 5.75 mg/kg | NE yagabanutse kugeza kuri 87 ku ijana; epinephrine igabanuka 81 ku ijana; dopamine igabanuka 40 ku ijana | MAP yari hejuru ku buryo bufite ubusobanuro bw'ibarurishamibare ku masaha 6 na 24 | Impfu mu minsi 28: 5 muri 10 ugereranyije na 7 muri 10; ntabwo ryari igerageza rigamije gupima impfu | Inkari z'ubururu n'ihinduka ry'ibara ry'uruhu; nta kimenyetso cy'uburozi bukomeye ku ngingo |
| Memis 2002: ubwandu bukomeye butera imikorere mibi y'umubiri, 15 ugereranyije na 15 | 0.5 mg/kg ku isaha mu gihe cy'amasaha 6 | Nta gipimo cyateganyijwe cyo kubara igabanuka ry'imiti | MAP nyuma yo gutanga umuti: 85 ugereranyije na 74 mmHg | Umubare w'abarwayi ntiwari uhagije ngo upime itandukaniro ry'impfu | Nta kimenyetso cy'uburozi bukomeye cyatangajwe |
| Ibarra-Estrada 2023: shoki iterwa n'ubwandu, 91 basesenguwe | Gutanga buhoro mu mutsi mu gihe cy'amasaha atandatu buri munsi, inshuro eshatu | Igihe cyo guhagarika imiti izamura umuvuduko w'amaraso cyari gifite agaciro ko hagati k'amasaha 69 ugereranyije n'amasaha 94 | Umuvuduko wagenzurwaga kugira ngo ugere ku rwego rwifuzwa mu matsinda yombi | Impfu zari zisa mu matsinda yombi | Inkari z'ubururu cyangwa icyatsi zari zisanzwe; abafite ibura rya G6PD n'abaherutse gukoresha SSRI ntibemerewe kwitabira |
| Dong 2025: shoki iterwa n'ubwandu ku barwayi bafashwa guhumeka, 36 ugereranyije na 36 | 2 mg/kg mu minota 15 hiyongereyeho 1 mg/kg mu masaha 12 | Itandukaniro rya NE ryari hafi ya zeru; nta tandukaniro mu gihe cyo guhagarika imiti izamura umuvuduko w'amaraso | Itandukaniro rya MAP ryari munsi ya zeru ho 1.2 mmHg, ridafite ubusobanuro bw'ibarurishamibare; itembera ry'amaraso mu miyoboro mito ryarushijeho kuba ryiza | Impfu mu minsi 28: 9 muri 36 ugereranyije na 15 muri 36, nta tandukaniro rifite ubusobanuro bw'ibarurishamibare | Inkari z'ubururu cyangwa icyatsi ku barwayi bose bahawe umuti; nta kimenyetso cy'ingaruka ku mwijima, impyiko cyangwa ku kugeza ogisijeni mu maraso |
Ese hari muri ibi bigaragaza impfu nke?
Isesengura rihuza ibyavuye mu magerageza ryagaragaje ibisubizo bisa n'ibyiza kurusha iby'igerageza rimwe rimwe, ariko ibyo bipimo byiza biracogora iyo bisuzumwe neza. Isesengura ryo mu 2024 ryahuje igerageza ritandatu kuri shoki iterwa n'ubwandu ryasanze igipimo cy'igereranya ry'ibyago byo gupfa mu gihe gito cya 0.66, ariko iyo ngaruka yatakaje ubusobanuro bw'ibarurishamibare igihe hakurwagamo igerageza rifite ibyago byinshi byo kubogama. Isesengura riheruka kurusha ayandi rihuza gusa igerageza rigabanya abarwayi mu matsinda ku buryo bwa tombola (RCT), ririmo igerageza icyenda n'abarwayi 535, ryasanze igipimo cy'igereranya ry'amahirwe yo gupfa mu minsi 28 kugeza kuri 30 cya 0.73, gifite intera y'icyizere kuva kuri 0.40 kugeza kuri 1.36. Ibyo ntibifite ubusobanuro bw'ibarurishamibare, kandi isesengura ryaryo ry'igerageza mu ruhererekane ryagereranyije ko hakenewe abarwayi 1,773, aho kuba magana make aboneka. Umwanzuro utabogamye ni uko inyungu yo kongera amahirwe yo kurokoka itarahamijwe, si uko byahamijwe ko itabaho.
Ibyerekeye umutekano biva mu bimenyetso byo mu bitaro
Ingaruka zakunze kugaragara mu igerageza zari inkari z'ubururu cyangwa icyatsi n'ihinduka ry'ibara ry'uruhu, hamwe n'izamuka rito rya methemoglobin. Ibyago bikomeye bishingiye ku makuru yemewe y'igicuruzwa gitangwa mu mutsi aho gushingira ku mubare w'ingaruka wabonetse mu igerageza: ihuriro ry'ibimenyetso biterwa na serotonin iyo bihujwe n'imiti ikora kuri serotonin cyangwa opioids; kubuza ikoreshwa ku bafite ibura rya G6PD kubera ibyago byo gusenyuka kw'insoro zitukura; ibipimo by'ogisijeni bitari byo biri hasi, bipimwe n'igikoresho gipimira ku ruhu mu gihe cyo gutanga umuti buhoro mu mutsi no nyuma gato yaho; n'umuvuduko ukabije w'amaraso watangajwe nk'ingaruka mbi. Igerageza rishya ritari rimwe ryakuyemo abarwayi bafite ibura rya G6PD cyangwa abaherutse gukoresha imiti ikora kuri serotonin. Bityo, imbonerahamwe zaryo zitagaragaza ibibazo by'umutekano ntizipima ibyago muri ayo matsinda. Ibi bimenyetso na byo bikwiye gusomwa hamwe n'incamake yagutse y'ikoreshwa mu buvuzi n'isuzuma ry'umutekano; abasomyi batamenyereye uburyo igerageza ritegurwa bashobora guhera ku nyandiko ibayobora mu gusoma ubushakashatsi ku bururu bwa metilene.
Vasoplegia na shoki iterwa n'ubwandu bishobora kuzakenera isesengura ryimbitse ritandukanye kuri buri imwe niba ibimenyetso byiyongereye. Ariko inyandiko z'ubushakashatsi zihari ubu zikwiranye n'isesengura rimwe ry'ubuvuzi bw'abarembye: hari ingaruka nyakuri zo kwikanya kw'imiyoboro y'amaraso no kugabanya imiti izamura umuvuduko wayo, zigaragara neza cyane kuri vasoplegia yamaze kubaho no kuri shoki iterwa n'ubwandu ikiri mu ntangiriro, ariko nta nyungu ku kurokoka yagaragajwe, kandi hari imipaka y'umutekano ibuza amatsinda menshi y'abarwayi kubukoresha. Umuntu wese ufite ibyo bibazo aba asanzwe ari mu buvuzi bw'abarembye, kandi ubururu bwa metilene muri iyo mimerere ni icyemezo gifatirwa mu ishami ryita ku barwayi barembye (ICU) n'itsinda rimuvura, si ubuvuzi bwo mu rugo bwakwanzurwa hashingiwe ku gutanga umuti mu mutsi mu bitaro.