Chinyorwa
Methylene blue yevasoplegia neshock inokonzerwa nehutachiona: zvinoratidzwa nezvidzidzo zvekiriniki
Murwere anobuda mukamuri rekuvhiyira mushure mekuvhiyiwa mwoyo, mwoyo uchipomba ropa pamwero wakajairika asi BP isingagari yakakwana. Pane mumwe mubhedha, murwere ane hutachiona hwakanyanya anoda madosi anoramba achiwedzera enorepinephrine kuti BP irambe iri pamusoro pemwero wakatarwa. Muzviitiko zvose izvi, tsinga dzinenge dzarasikirwa nekusimba kwadzo, uye zvose zvakaita kuti vanachiremba vanochengeta varwere vanorwara zvakanyanya vaedze methylene blue. Chinyorwa ichi chinoongorora zvakanyatsoedzwa nezvidzidzo zvekiriniki uye zvazvakawana.
Misiyano miviri ndiyo inoronga zvose zviri pasi apa. Wokutanga, vasoplegia mushure mekuvhiyiwa mwoyo neshock inokonzerwa nehutachiona zvirwere zvakasiyana uye zvidzidzo zvazvo zvakagadzirwa nenzira dzakasiyana, saka chimwe nechimwe chine chikamu chacho. Wechipiri, kuda mishonga mishoma inosimbisa tsinga hakufanani nekuwedzera kwemukana wekurarama. Zvidzidzo zvizhinji zvakayera chokutanga; zvinenge zvose zvakanga zvisina varwere vakakwana kuti zvigadzirise mubvunzo wechipiri.
Nei methylene blue ingawedzera kusimba kwetsinga
Tsinga dzinotakura ropa kubva pamwoyo dzinotetepa nekufara apo tsandanyama dzadzo dzakatsetseka dzinobatana nekuzorora, uye kufara kwadzo ndiko kunonyanya kutara kushorwa kwekuyerera kweropa mutsinga dzomuviri wose. Chimwe chiratidzo chekuzorora chinotangira panitric oxide, chichipfuura nep soluble guanylate cyclase kuenda kucyclic GMP, iyo inokurudzira kuzorora kwetsandanyama. Methylene blue inovhiringidza nzira iyi, ndokusaka ichigona kupikisa kuwedzera kukuru kwetsinga kunoitika pashock. Mashandiro emushonga uyu akakura kupfuura kungovhara nzvimbo imwe chete: muongororo dzekuedza pamusoro pekugadzirwa kwenitric oxide nekuzorora kwetsinga, methylene blue yakashanda panzvimbo dzinopfuura imwe munhevedzano yezviratidzo izvi. Ongororo iyoyo inotsanangura mashandiro anogona kunzwisisika. Haifanotauri kuti BP yemurwere mumwe nomumwe ichapindura sei.
Chidzidzo chose chiri pasi apa chakashandisa methylene blue inopinzwa mutsinga muchipatara, ichiwedzerwa pakuchengetwa kwakajairika kwevarwere vanorwara zvakanyanya. Hapana pano panoedza chigadzirwa chinonwiwa kumba.
Vasoplegia mushure mekuvhiyiwa mwoyo
Vasoplegia pano inoreva kuderera kwakanyanya kwekusimba kwetsinga mushure mekushandiswa kwemuchina unotsiva basa remwoyo nemapapu panguva yekuvhiya: BP yakaderera nekushorwa kushoma kwekuyerera kweropa, kunyange mwoyo uchiri kupomba ropa zvakakwana. Uchapupu hunobva muzvidzidzo zvakagovera varwere mumapoka nemukana pamusoro pekurapa vasoplegia yatovapo hunonyanya kutsamira pachidzidzo chimwe chidiki. Zvimwe zvidzidzo zviviri zvakaedza methylene blue isati yatanga kana panguva yekuvhiya kudzivirira vasoplegia, unova mubvunzo wakasiyana wekiriniki.
Muchidzidzo chaLevin nevamwe chakagovera varwere nemukana, chichiongorora vasoplegia yatovapo mushure mekuvhiyiwa, varwere 56 vakagoverwa kuti vapiwe 1.5 mg/kg yakapinzwa mutsinga muawa imwe kana placebo. Vasoplegia yakapera nokukurumidza muboka rakapiwa mushonga, asi varwere 8 pa28 vakapiwa placebo vakaramba vaine vasoplegia kweanopfuura maawa 48, uye vakafa vaiva 0 pa28 zvichienzaniswa ne6 pa28. Kupedzwa kweshock uku kunoshamisa, asi varwere 56 havakwanisi kusimbisa kubatsira pakurarama, uye musiyano werufu uyu hauna kusimba zvakakwana kuti ushandiswe pakutaura nezvevarwere vose.
Zvidzidzo zvekudzivirira hazvina kuwana zvakafanana. Muchidzidzo chaOzal nevamwe chevarwere vaiva panjodzi huru vaivhiyiwa kugadzira nzira itsva yeropa pamwoyo, kupinzwa kwemushonga mutsinga vasati vavhiyiwa kwakaderedza vasoplegia kubva pa13 pa50 kusvika pa0 pa50. Maslow nevamwe vakawana shanduko yakagara kwenguva pfupi panguva yekushandiswa kwemuchina unotsiva basa remwoyo nemapapu, asi Cho nevamwe havana kuwana zvinenge chero zvakanakira kufamba kweropa kana kushandiswa kwemishonga inosimbisa tsinga. Kudzivirira muvarwere vakasarudzwa vanovhiyiwa nekurapa vasoplegia yatovapo zvinofanira kuverengwa sezvinhu zvakasiyana zvine uchapupu hwakasiyana.
Shock inokonzerwa nehutachiona
Shock inokonzerwa nehutachiona inosanganisa hutachiona nekutadza kwekutenderera kweropa kunoramba kuripo kunyange mushure mekupiwa zvinwiwa mutsinga, saka norepinephrine inova hwaro hwekurapa uye zvidzidzo zvinobvunza kana methylene blue ichipfupisa nguva yekupiwa macatecholamine. Zvinoratidzwa nezvidzidzo izvi zvinowirirana kupfuura zvekuvhiyiwa, asi zvichiri kusiyana, uye zvine chekuita nekuderedza mishonga inosimbisa tsinga pane kuwedzera kurarama.
Chidzidzo chikuru chemazuva ano ndechechidzidzo chaIbarra-Estrada nevamwe cha2023 chakagovera varwere nemukana kuti vaedze methylene blue yekuwedzera pakurapa ichitangwa nokukurumidza, umo vanhu vakuru 91 vakabatanidzwa mukuongorora vakapiwa mushonga mutsinga kwemaawa matanhatu zuva nezuva kwemadosi matatu kana placebo inoenderana nawo, pamusoro penorepinephrine, hydrocortisone, nevasopressin pazvaidiwa. Nguva yepakati kusvika pakumisa mishonga inosimbisa tsinga yaiva maawa 69 zvichienzaniswa nemaawa 94, asi mwero werufu nenguva yekubatsirwa kufema nemuchina zvakanga zvakafanana. Zvidzidzo zvekare zvakanga zvidiki: chidzidzo chekutanga chaKirov nevamwe chevarwere 20 chakaratidza kuderedzwa kukuru kwemacatecholamine mushure medosi rimwe re2 mg/kg rakapiwa nokukurumidza, richiteverwa nemushonga waipinzwa mutsinga uchiramba uchiwedzerwa. Memis nevamwe vakawana avhareji yepamusoro yeBP mutsinga dzinotakura ropa kubva pamwoyo mushure mekupinzwa kwemushonga (85 zvichienzaniswa ne74 mmHg), asi havana kuyera kuderedzwa kwemishonga inosimbisa tsinga semugumisiro wechidzidzo. Zvichipesana neizvi, chidzidzo chaDong nevamwe chevarwere 72, chaienzanisa mushonga neplacebo, hachina kuwana musiyano une zvaunoreva pakushandiswa kwenorepinephrine kana paBP. Kumwe kuenzanisa kwakawana kuti vasopressin yaipfuura methylene blue payaishandiswa semushonga wechipiri unosimbisa tsinga pamaawa 12 ne24. Basa rekutsvaga dosi rakaitwa naJuffermans nevamwe rakaratidza kuti BP nekushorwa kwekuyerera kweropa zvakakwira sezvo dosi raiwedzera, asi pa7 mg/kg paiva nekushushikana pamusoro pekuderera kweropa rinosvika kunhengo dzemudumbu.
Tafura yezvidzidzo
IV zvinoreva kupinzwa mutsinga. NE zvinoreva norepinephrine. MAP zvinoreva avhareji yeBP mutsinga dzinotakura ropa kubva pamwoyo. SVR zvinoreva kushorwa kwekuyerera kweropa mutsinga dzomuviri wose. Mutsara mumwe nomumwe unoratidza zvakapiwa muchidzidzo, kwete kurudziro yekurapa.
| Chidzidzo nemamiriro acho | Marongerwo ekupiwa mushonga | Mugumisiro pamishonga inosimbisa tsinga | Mugumisiro pakufamba kweropa | Rufu | Zviitiko zvisingadiwi |
|---|---|---|---|---|---|
| Levin 2004: vasoplegia yatovapo mushure mekuvhiyiwa mwoyo, 28 zvichienzaniswa ne28 | 1.5 mg/kg IV muawa 1 | Vasoplegia yakapera muvarwere vose vakapiwa mushonga mukati memaawa 6; 8 pa28 veboka rekuenzanisa vakaramba vanayo kweanopfuura maawa 48 | MAP neSVR zvakadzokera nokukurumidza muboka rakapiwa mushonga | 0 pa28 zvichienzaniswa ne6 pa28; chidzidzo chidiki zvikuru kuti chisimbise kubatsira pakurarama | Hapana chiratidzo chikuru chekukuvadza kwemushonga chakataurwa pamarongerwo aya |
| Ozal 2005: kudzivirira muvarwere 100 vaiva panjodzi huru vaivhiyiwa vachishandisa muchina unotsiva basa remwoyo nemapapu, 50 zvichienzaniswa ne50 | Mushonga wemvura we1 percent wakatanga kupinzwa mutsinga awa 1 kuvhiya kusati kwatanga | Vasoplegia 0 pa50 zvichienzaniswa ne13 pa50; kudzivirira, kwete kurapa yatovapo | BP yakakwirira panguva yekuvhiya muboka rakapiwa mushonga | Hachisi chidzidzo cherufu | Hapana chiratidzo chikuru chekukuvadza kwemushonga chakataurwa |
| Cho: methylene blue yekudzivirira pakuvhiyiwa mwoyo | Kupinzwa mutsinga panguva yakapoteredza kuvhiya | Hapana musiyano unokosha maererano nenhamba mumishonga inosimbisa tsinga | MAP neSVR hazvina kusiyana zvakakosha maererano nenhamba | Hachisi chidzidzo cherufu | Hapana mwero wezviitiko zvisingadiwi wakataurwa zvakanangana nazvo |
| Kirov 2001: chidzidzo chekutanga cheshock inokonzerwa nehutachiona, 10 zvichienzaniswa ne10 | Dosi rimwe re2 mg/kg rakapiwa nokukurumidza, richiteverwa nekupinzwa mutsinga kuchiwedzerwa nhanho nenhanho kusvika pa5.75 mg/kg yose | NE yakaderedzwa kusvika pa87 percent; epinephrine yakadzikira ne81 percent; dopamine yakadzikira ne40 percent | MAP yakakwira zvakakosha maererano nenhamba pamaawa 6 ne24 | Vakafa mumazuva 28 vaiva 5 pa10 zvichienzaniswa ne7 pa10; hachisi chidzidzo cherufu | Weti yebhuruu nekushanduka kweruvara rweganda; hapana chiratidzo chikuru chekukuvadzwa kwenhengo |
| Memis 2002: sepsis yakanyanya, 15 zvichienzaniswa ne15 | 0.5 mg/kg paawa kwemaawa 6 | Hapana mugumisiro wekuderedzwa kwemishonga wakayerwa nenhamba | MAP mushure mekupinzwa kwemushonga 85 zvichienzaniswa ne74 mmHg | Hachina varwere vakakwana kuti chiongorore rufu zvakavimbika | Hapana chiratidzo chikuru chekukuvadza kwemushonga chakataurwa |
| Ibarra-Estrada 2023: shock inokonzerwa nehutachiona, 91 vakaongororwa | Kupinzwa mutsinga kwemaawa matanhatu zuva nezuva kwemadosi matatu | Nguva yepakati kusvika pakumisa mishonga inosimbisa tsinga maawa 69 zvichienzaniswa ne94 | BP yakachengetwa pamwero wakatarwa mumapoka ose | Mwero werufu wakafanana mumapoka | Weti yebhuruu kana yegirini yaiwanzoitika; vane kushomeka kweG6PD nevakanga vachangobva kushandisa SSRI havana kubatanidzwa |
| Dong 2025: shock inokonzerwa nehutachiona muvarwere vaibatsirwa kufema nemuchina, 36 zvichienzaniswa ne36 | 2 mg/kg mumaminitsi 15 pamwe ne1 mg/kg mumaawa 12 | Musiyano weNE waiva pedyo nezero; hapana musiyano panguva kusvika pakumisa mishonga inosimbisa tsinga | Musiyano weMAP waiva minus 1.2 mmHg, usina kukosha maererano nenhamba; kuyerera kweropa mutsinga diki kwakavandudzika | Vakafa mumazuva 28 vaiva 9 pa36 zvichienzaniswa ne15 pa36, zvisina kukosha maererano nenhamba | Weti yebhuruu kana yegirini muvarwere vose vakapiwa mushonga; hapana chiratidzo chekukanganiswa kwechiropa, itsvo, kana kupiwa kweokisijeni |
Pane here chinoratidza kufa kwevanhu vashoma?
Ongororo dzakabatanidza zvidzidzo dzakaratidza zvinovimbisa kupfuura zvidzidzo zvimwe nezvimwe, asi fungidziro dzakanaka idzi dzinopera simba padzinoongororwa zvakadzama. Ongororo ya2024 yakabatanidza zvidzidzo zvitanhatu zveshock inokonzerwa nehutachiona yakawana reshiyo yenjodzi yerufu rwenguva pfupi ye0.66, asi mugumisiro uyu wakarasikirwa nekukosha maererano nenhamba pakabviswa zvidzidzo zvaiva nenjodzi huru yekurerekera pakuwana mhedzisiro. Ongororo yazvino zvikuru yakabatanidza zvidzidzo zveRCT chete, ichibata zvidzidzo zvipfumbamwe nevarwere 535, yakawana reshiyo yemikana yerufu mumazuva 28 kusvika 30 ye0.73, ine muganhu wekuvimba kubva pa0.40 kusvika pa1.36, iyo isina kukosha maererano nenhamba. Ongororo yayo yakatevedzanisa zvidzidzo kuti ione kana uchapupu hwakanga hwakwana yakafungidzira kuti varwere 1,773 vaizodiwa, zvichienzaniswa nemazana mashoma aivapo. Pfupiso yakatendeseka ndeyekuti kubatsira pakurarama hakusati kwasimbiswa, kwete kuti kwakaratidzwa kuti hakuna.
Zvinyorwa zvekuchengeteka kubva muuchapupu hwezvipatara
Zvaiwanzoitika muzvidzidzo zvaiva weti yebhuruu kana yegirini nekushanduka kweruvara rweganda, pamwe nekukwira kudiki kwemethemoglobin. Njodzi dzakakomba dzinobva muruzivo rwechigadzirwa chine mvumo chinopinzwa mutsinga, kwete panhamba dzezviitiko zvakaitika muzvidzidzo: serotonin syndrome painosanganiswa nemishonga inokanganisa serotonin kana maopioid, kusafanira kushandiswa muvanhu vane kushomeka kweG6PD nekuda kwenjodzi yekuparara kwemasero matsvuku eropa, kuverengwa kwakaderera kwenhema nemudziyo unoyera okisijeni muropa panguva uye nguva pfupi mushure mekupinzwa kwemushonga, uye BP yakakwirira sechimwe chiitiko chisingadiwi chakataurwa. Zvidzidzo zvakawanda zvemazuva ano hazvina kubatanidza varwere vane kushomeka kweG6PD kana vakanga vachangobva kupiwa mishonga inokanganisa serotonin, saka matafura azvo anoratidza zviitiko zvishoma haayeri njodzi mumapoka iwayo. Uchapupu uhwu hunofanirawo kuverengwa pamwe neongororo yakafara yekushandiswa mukiriniki uye ongororo yekuchengeteka; vaverengi vasina kujairana nemagadzirirwo ezvidzidzo vanogona kutanga negwaro rinotsanangura kuverenga tsvakurudzo yemethylene blue.
Vasoplegia neshock inokonzerwa nehutachiona zvingazoda ongororo dzakadzama dzakaparadzana kana uchapupu hukawedzera, asi zvinyorwa zviripo zvino zvinokwana muongororo imwe yekuchengetwa kwevarwere vanorwara zvakanyanya: pane mugumisiro chaiwo wekumanikidza tsinga nekuderedza mishonga inosimudza BP, unonyatsooneka muvasoplegia yatovapo nemushock inokonzerwa nehutachiona ichangotanga, pasina kuwedzera kwekurarama kwakaratidzwa uye paine miganhu yekuchengeteka inosiya mamwe mapoka evarwere kunze. Munhu ane mamiriro aya anenge atova muchikamu chekuchengetwa kwevarwere vanorwara zvakanyanya, uye kushandisa methylene blue mumamiriro aya isarudzo yeICU inoitwa nechikwata chinomurapa, kwete kurapwa kumba kunofungidzirwa kubva pakupinzwa kwemushonga mutsinga muchipatara.