Methylene blue yemethemoglobinemia: nei ichishandiswa muzvipatara

Murwere anosvika aine miromo ine ruvara rwegrey yakaita sedombo reslate, achifema nekukurumidza uye achipindura zvishoma nezvishoma. Muchina wekutarisa unoratidza kuti kuzara kweropa neokisijeni kuri pa85 muzana. Mukoti anowedzera okisijeni. Nhamba yacho haichinji. Ropa rinotorwa uye rinobuda riri shava seruvara rwechokoreti, uye rinoramba riri shava kana raiswa pamhepo. Kutevedzana uku ndiko kunowanzoita kuti varwere vapinde mukurapwa kwemethemoglobinemia nemethylene blue, uye kunoratidza nei mamiriro aya achivhiringidza mhuri pamwe nemichina.

Dambudziko harisi mumapapu. Riri muayoni iri mukati mehemoglobin.

Mamiriro maviri eatomu rimwe chete reayoni

Morekuru rimwe nerimwe rehemoglobin rine ayoni iri muchimiro cheferrous, chinonyorwa kuti Fe2+. Muchimiro ichocho inosunga okisijeni mumapapu yoisunungura munyama dzemuviri. Makemikari anoita oxidation anogona kubvisa rimwe erekitironi kubva muayoni iyoyo, achiishandura kuita chimiro cheferric, Fe3+. Chinhu chine ruvara chinobva chagadzirwa chinonzi methemoglobin. Ayoni yeferric haigoni kusunga okisijeni, uye chakatonyanya kuipa ndechekuti inoita kuti dzimwe nzvimbo dzichiri muchimiro cheferrous mumorekuru rimwe chete dzibate okisijeni yadzo zvakasimba, saka okisijeni shoma ndiyo inosunungurwa painodiwa.

Ropa rine utano rinochengeta methemoglobin iri pasi peinenge 1 muzana nokuti enzayimu inoigadzirisa inoramba ichishanda. Nzira huru yekuigadzirisa inoshandisa NADH necytochrome b5 reductase, ichitsigirwa neglycolysis inowanzoitika musero dzvuku reropa. Imwe nzira yekubatsira inoshandisa NADPH, asi mumamiriro akajairika inoita basa shoma. Zviratidzo zvinowanzoenderana nehuwandu huri muzana, kunyange zvazvo anemia kana chirwere chemwoyo nemapapu zvingaita kuti nhamba yakaderera ive nenjodzi. Huwandu huri pedyo ne10 kusvika ku20 muzana hunogona kukonzera cyanosis inooneka, kureva ruvara rwebhuruu paganda, pamwe nekuneta. Huwandu hunopfuura 30 muzana hunowanzounza kutemwa nemusoro, kutadza kufema zvakanaka, uye kuvhiringidzika. Huwandu huri pedyo ne70 muzana hunowanzouraya. Nhamba idzi dzinoratidza mapoka ehuwandu, hadzivimbisi zvichaitika, nokuti chakakosha kusvitswa kweokisijeni, kwete nhamba yemurabhoritari yoga.

Zvinowanzokonzera mamiriro aya kana asiri ekuzvarwa nazvo zvinosanganisira dapsone, nitrites nenitrates, makemikari ane aniline, uye mishonga inoderedza kunzwa panzvimbo yaiswa yakadai sebenzocaine neprilocaine. Kushomeka kwemaenzayimu kwekuzvarwa nako kuripo asi hakuwanzoitiki. Varwere vakawanda vemuzvipatara vanenge vawana mamiriro aya mushure mekuzvarwa, zvinoreva kuti danho rekutanga rekurapa nguva dzose nderokumisa kusangana nechinhu chakaakonzera.

Mutakuri unoshandiswa nezvipatara

Methylene blue haiwedzeri okisijeni. Inobatsira kufambisa maerekitironi. Mukati mesero dzvuku reropa, enzayimu inoshandisa NADPH kuita reduction padhayi yebhuruu ichiiita chimiro chayo chisina ruvara, leucomethylene blue. Chimiro ichocho chisina ruvara chinozopa maerekitironi kuayoni yeferric pasina kushandisa enzayimu, chichidzorera hemoglobin ine ayoni yeferrous, chobva chadzokera kuchimiro chebhuruu. Dhayi yacho inoramba ichitenderera pakati pezvimiro izvi. Kutambidzana kwacho kunotsanangurwa mumashandiro anoita methylene blue pakufambisa maerekitironi pakati pevanoapa nevanoagamuchira, uye chimiro chisina ruvara chakaitwa reduction chinotsanangurwa mukuenzanisa methylene blue neleucomethylene blue.

Mashandiro aya anotsanangura miganhu miviri inoshamisa vanhu vachangotanga kudzidza nezvayo. Chekutanga, mutakuri uyu unoda NADPH, uye NADPH yemusero dzvuku reropa inotsamira paglucose-6-phosphate dehydrogenase, G6PD. Kana G6PD ichishomeka, dhayi inogona kutadza kushandurwa kuita chimiro chayo chinoshanda uku ichiwedzerawo kushushikana kunokonzerwa neoxidation, ndokusaka gwaro remushonga unoshandiswa muchipatara richiti haifaniri kushandiswa kana G6PD ichishomeka. Chechipiri, methylene blue pachayo inoita oxidation kana madhosi akaunganidzwa akawandisa. Kana huwandu hwose hwapfuura inenge 7 mg pa kg, kana dzimwe nguva hwakaderera pane izvozvo pakudzokorora madhosi, inogona kuwedzera methemoglobin nekuparadza masero matsvuku eropa panzvimbo pekuagadzirisa. Dhayi yakawanda hairevi kununura kwakawanda. Muganhu wedhosi wakaiswa uri mutete nemaune.

Nei muyedzo unoita seuri pachena uchitsausa

Mhuri dzinowanzotsvaga muyedzo wemethylene blue wadzinogona kuita kumba. Hapana muyedzo wakadaro. Mashoko aya anowanzoreva kuongororwa kunoitwa kana methemoglobinemia ichifungidzirwa, uye kuongorora ikoko kunofanira kuitirwa murabhoritari.

Mapulse oximeter akajairika anoverenga chiedza chine hurefu hwemasaisai huviri chete. Methemoglobin painowedzera, kusvetwa kwechiedza pahurefu hwemasaisai ihwohwo huviri kunoswedera pakuenzana, uye huwandu hwekuzara neokisijeni hunoratidzwa hunoswedera painenge 85 muzana pasinei nemamiriro chaiwo. Kuwedzera okisijeni hakugadzirisi nhamba yacho nokuti sensor haisi kuyera chiri kukanganisika. Kudzvinyirira kweokisijeni muropa remutsinga inobva pamwoyo, PaO2, kunogona kuratidzika kunge kwakajairika panguva imwe chete, nokuti kunoyera okisijeni yakanyunguduka muplasma panzvimbo peokisijeni yakatakurwa nehemoglobin. Saka muchina unoongorora magasi eropa uchiverenga kuzara neokisijeni kubva paPaO2 unogona kuratidza nhamba inonyaradza murwere achiri kuratidza cyanosis. Musiyano pakati pechiyero chemudziyo wepamunwe nechiyero chakaverengwa cheropa remutsinga inobva pamwoyo, unowanzopfuura mapoinzi 5 ehuwandu hwemuzana, unonzi saturation gap; chiratidzo chinobatsira kuongorora, kwete chisimbiso chechirwere.

Kusimbisa kunoda co-oximetry inoshandisa hurefu hwemasaisai akawanda pasampuli yeropa, iyo inoyera methemoglobin zvakananga. Ropa riri shava sechokoreti risingashanduki ruvara parinopiwa okisijeni rinonongedzawo kumamiriro mamwe chete. Chero chisarudzo chekurapa methemoglobinemia chinotanga pachiyero ichocho pamwe nezviratidzo, kwete papulse oximeter yoga.

Marapirwo anotarisirwa anotsanangurwa mugwaro remushonga

Chikamu chino chinotsanangura jekiseni rinopiwa nenyanzvi dzeutano richida kunyorerwa nachiremba. Haisi nhungamiro yekushandisa mushonga nemuromo, uye hapana pamashoko aya panoshanda pamadonhwe kana makapisi anotengeswa kuti vanhu vazvishandise.

Mashoko aripo ekunyora mushonga wejekiseni remethylene blue anotsanangura kurapwa kwemethemoglobinemia isiri yekuzvarwa nayo muvakuru nevana se1 mg pa kg inopiwa mutsinga mukati memaminitsi 5 kusvika ku30. Pachigadzirwa chakajairika chine 5 mg pa mL, izvi zvakaenzana ne0.2 mL pa kg. Kana methemoglobin ikaramba iri pamusoro pe30 muzana kana zviratidzo zvikaramba zviripo mushure meawa imwe, dhosi rechipiri re1 mg pa kg rinogona kupiwa. Kana madhosi maviri akasagadzirisa dambudziko, gwaro rinorayira nyanzvi dzeutano kushandisa imwe nzira yekurapa panzvimbo pedhosi rechitatu.

Mashoko ekuti mushonga unopiwa sei akakosha. Panofanira kushandiswa mutsetse wemutsinga unoshanda zvakanaka, kwete kubaya pasi peganda. Mushonga wacho unogona kuderedzwa kukora nekuiswa mu50 mL yedextrose ye5 muzana kuti marwadzo epanzvimbo paunopiwa aderedzwe, kunyanya muvana, uye unofanira kushandiswa pasina kunonoka. Haufaniri kuderedzwa kukora nemvura dzine sodium chloride, nokuti chloride inoderedza kunyunguduka kwedhayi. Zvikamu zvisina kushandiswa zvinoraswa uye mushonga wacho unoongororwa usati washandiswa.

Yambiro nhatu dzinotungamirira chisarudzo chega chega muchipatara. Yambiro yakaiswa mubhokisi inotaura nezveserotonin syndrome, inogona kuuraya kana methylene blue ikasangana nemishonga ine chekuita neserotonin, inosanganisira SSRIs, SNRIs, MAO inhibitors, mamwe maopioid, nedextromethorphan. Varwere vanoudzwa kuti vasatora mishonga yakadaro kwemaawa 72 mushure medhosi rekupedzisira, uye kana kusanganiswa kwacho kusingagoni kudziviswa, gwaro rinoda kuti pashandiswe dhosi rakaderera kupfuura mamwe ose rinobvira, murwere achinyatsotarisirwa. Kudyidzana kwemishonga kune chekuita neserotonin kunotsanangurwa mukudyidzana kwemethylene blue nemimwe mishonga uye serotonin syndrome. Hemolysis ndiyo yambiro yechipiri: kuparara kwemasero matsvuku eropa kunofambidzana nemaHeinz bodies, kuwedzera kweindirect bilirubin, kuderera kwehaptoglobin, uye anemia inogona kuoneka mushure mezuva rimwe kana kuti gare gare uye ingada kuwedzerwa ropa. Yechitatu ndeyekurasikirwa nesimba rekushanda kana kudzoka kwemamiriro acho, zvinoonekwa pakusangana nedapsone kana makemikari erudzi rweaniline uye pakushomeka kweG6PD, apo gwaro rinonongedzazve kune imwe nzira yekurapa. Kusashanda zvakanaka kweitsvo hakurambidzi kushandiswa, asi kana kuri kwepakati nepakati kusvika kwakanyanya, kurapwa kunogumira padhosi rimwe chete re1 mg pa kg. Zviitiko zvisingadiwi zviri mudata revakuru riri mugwaro zvaisanganisira kutemwa nemusoro, kusvotwa, manyoka, kuderera kwepotassium nemagnesium, kukwakuka kwemhasuru, uye zviitiko zvakaita sekubatwa nepfari, paine chiitiko chimwe chakakomba chakaita sekubatwa nepfari pakati pevarwere 31. Dhayi inoderedzawo zvisiri izvo zviverengo zvepulse oximeter mushure mekupinzwa mutsinga, saka nyanzvi dzeutano dzinotevera co-oximetry nezviratidzo panzvimbo pazvo.

Rubatsiro runotsigira murwere runoitwa panguva imwe chete: okisijeni inoyerera zvakawanda, kutsigira nzira yekufema nekufamba kweropa, kugadzirisa glucose, uye kutarisira murwere. Mamiriro asina kunyanya kuipa uye asina zviratidzo anogona kupera kana chinhu chakaakonzera chabviswa. Miganhu inowanzotaurwa ndeyekurapa varwere vane zviratidzo kubva painenge 20 muzana, kana kubva pa10 kusvika ku20 muzana kana kusvitswa kweokisijeni kwatova nedambudziko, uye kufunga nezvekurapa varwere vasina zviratidzo kubva painenge 30 muzana. Zviratidzo zvakakomba zvinorapwa pasina kumirira nhamba yemurabhoritari. Ascorbic acid, kutsiviwa kweropa nekubvisa rimwe richitsiviwa nerimwe, uye okisijeni inopiwa pasi pekudzvinyirira kwakakwirira inzira dzekununura kana methylene blue isingagoni kushandiswa kana ikatadza kushanda, asi ascorbic acid inoshanda zvishoma nezvishoma zvikuru. Zvinyorwa zvinoratidza kuchena kwechigadzirwa chipi nechipi chinobayiwa inyaya yakasiyana ine chekuita nekugadzirwa kwacho, inotsanangurwa mumaverengero echitupa chekuongororwa kwemethylene blue.

Benzocaine nemubvunzo wegel yekumera mazino

Chikamu chikuru chekutsvaga kunoitwa nevatengi chinobva kuvabereki vanenge vashandisa gel kana spray yemuromo ine benzocaine, vozowona miromo yebhuruu kana nhamba yakaderera paoximeter. Matanho matatu anofanira kuramba akaparadzaniswa.

Kufungidzira kuti munhu asangana nechinhu chinokonzera mamiriro aya ndiro danho repamba. Benzocaine inozivikanwa sechinhu chinokonzera oxidation, uye masangano anodzora mishonga akayambira kuti zvigadzirwa zvemumuromo zvine benzocaine zvinotengwa pasina kunyorerwa nachiremba hazvifaniri kushandiswa pakumera mazino kana muvana vari pasi pemakore 2, nokuti methemoglobinemia ine chekuita nebenzocaine inogona kuva yakakomba uye kubatsira kwayo pakurwadziwa kwekumera mazino kushoma. Rega kushandisa chigadzirwa chacho, nyora nguva nehuwandu hwakashandiswa, cherechedza zviratidzo zvakadai sekucheneruka kusina kujairika, ruvara rwegrey kana rwebhuruu pamiromo nepasi pezvipikiri, kutadza kufema zvakanaka, kukotsira kusina kujairika, kana kusadya zvakanaka, uye tsvaga kuongororwa kwechimbichimbi pasina kunonoka. Usapa methylene blue kumba chero iri muchimiro chipi. Hapana dhosi rekumba uye hapana muyedzo wepamba unogona kuratidza kuti mamiriro aya haapo.

Kuonekwa kuti chirwere chacho ndechipi ndiro danho remuchipatara. Nyanzvi dzeutano dzinosimbisa neco-oximetry, dzinoongorora kusangana kwose nezvinhu zvinoita oxidation kusanganisira dapsone, nitrites, nemakemikari ane aniline, uye dzinoongorora zviratidzo nekusvitswa kweokisijeni panzvimbo pekutarisira nhamba imwe chete yakazvimirira.

Kurapwa kuchitarisirwa ndiro danho remuwadhi ratsanangurwa pamusoro. Kuti benzocaine ndiyo yakakonzera mamiriro aya kana kwete hakuchinji tafura yemadhosi. Gwaro rejekiseni riripo haritauri benzocaine zvakananga; mamiriro akakonzerwa nebenzocaine anowira pasi pemethemoglobinemia isiri yekuzvarwa nayo uye anorapwa nenzira imwe chete inotarisirwa, inosanganisira kuongororwa kweG6PD, itsvo, neserotonin.

Kana methylene blue isiri mhinduro

Haisi mhinduro kana kushomeka kweG6PD kuchizivikanwa. Haisi mhinduro mushure mekunge madhosi maviri anotsanangurwa mugwaro atadza kushanda kana methemoglobinemia yadzoka, izvo zvinonongedzera kukuramba kuchitorwa nemuviri kwemishonga yakadai sedapsone. Haisi mhinduro yekudzivirira mamiriro aya, yekushandiswa nguva dzose sechinowedzerwa pakudya, kana yekurapa kumba mushure mekusangana nekemikari. Kushandisa dhosi rakakwirira kana kudzokorora kushandiswa kunogona kuita kuti nhamba chaiyo yainofanira kuderedza iwedzere, uye hemolysis inogona kuoneka mushure mezuva rimwe murwere atova kumba. Njodzi iyoyo inononoka kuoneka ndicho chimwe chezvikonzero zvinoita kuti zvipatara zvirambe zvichitarisira varwere pane kukurumidza kuvabudisa.

Pfupiso yechokwadi ipfupi. Methemoglobinemia ine chekuita neayoni yakaitwa oxidation isingagoni kutakura okisijeni. Methylene blue mutakuri wemaerekitironi unobvumira masero matsvuku eropa kuita reduction paayoni iyoyo, kana sero richikwanisa kugadzira NADPH uye kana dhosi richiramba riri mukati memiganhu yakamanikana yekurapwa inotsanangurwa mugwaro. Kuongorora kunoda co-oximetry nokuti michina iri nyore inotsausa. Zvimwe zvose, kubva padextrose inoshandiswa kuderedza kukora kwemushonga kusvika panhoroondo yemishonga ine chekuita neserotonin uye pachubhu yebenzocaine iri mukabati yemishonga, mashoko anotsigira basa remutakuri mumwe chete iyeye.