Inqaku
Imethylene eluhlaza okwesibhakabhaka kwivasoplegia nakumothuko we-sepsis: oko kuboniswa zizilingo zekliniki
Isigulana siphuma kwigumbi lotyando emva kotyando lwentliziyo, isixa segazi esimpontshwa yintliziyo siqhelekile kodwa uxinzelelo lwegazi aluzinzi. Komnye umandlalo, isigulana esinosulelo oluqatha sidinga iidosi ezandayo zenorepinephrine ukuze uxinzelelo luhlale lungaphezu kwenqanaba ekujoliswe kulo. Zombini ezi meko zibandakanya imithambo yegazi ephulukene nokuqina kwayo, kwaye zombini zikhokelele iingcali zokhathalelo olunzulu ekuzameni imethylene eluhlaza okwesibhakabhaka. Eli nqaku liphonononga oko izilingo zekliniki zakuvavanyayo ngokwenene noko zakufumanisayo.
Imiba emibini eyahlukileyo ilungelelanisa konke oku kulandelayo. Okokuqala, ivasoplegia emva kotyando lwentliziyo nomothuko we-sepsis zizifo ezahlukileyo, ezinezilingo ezilungiselelwe ngeendlela ezahlukileyo, ngoko nganye inecandelo layo. Okwesibini, ukufuna amayeza ambalwa anyusa uxinzelelo lwegazi akufani nokuba baninzi ngakumbi abasindayo. Uninzi lwezilingo lwalinganisa eyokuqala; phantse akukho nalunye olwalulukhulu ngokwaneleyo ukuqinisekisa eyesibini.
Kutheni imethylene eluhlaza okwesibhakabhaka inokunyusa ukuqina kwemithambo yegazi
Imithambo ehambisa igazi lisuka entliziyweni iyacutheka ize yande njengoko izihlunu zayo ezigudileyo zishwabana zize ziyekelele, kwaye ububanzi bayo bumisela inxalenye enkulu yoxhathiso lwemithambo yegazi emzimbeni wonke. Omnye umqondiso wokuyekelela uqala kwinitric oxide, udlule kwi-guanylate cyclase enyibilikayo, uye kwi-GMP ejikelezayo, ekhuthaza ukuyekelela. Imethylene eluhlaza okwesibhakabhaka iphazamisa le ndlela, nto leyo ebangela ukuba ikwazi ukuchasana nokwanda okugqithisileyo kwemithambo yegazi okubangelwa ngumothuko. Indlela esebenza ngayo ayipheleli ekuthinteleni into enye kuphela: kumsebenzi wolingo ngokwenziwa kwenitric oxide nokuyekelela kwemithambo yegazi, imethylene eluhlaza okwesibhakabhaka yasebenza kwiindawo ezingaphezu kwenye kuthotho lokudluliselwa komqondiso. Loo msebenzi uchaza indlela yokusebenza enokubakho. Awuxeli kwangaphambili ukuba uxinzelelo lwegazi lwesigulana ngasinye luya kusabela njani.
Ulingo ngalunye olungezantsi lwasebenzisa imethylene eluhlaza okwesibhakabhaka efakwa emthanjeni esibhedlele, ukongeza kukhathalelo olunzulu oluqhelekileyo. Akukho nto apha evavanya imveliso eselwa ngomlomo ekhaya.
Ivasoplegia emva kotyando lwentliziyo
Ivasoplegia apha ithetha ukuncipha kakhulu kokuqina kwemithambo yegazi emva kokusetyenziswa komatshini othatha umsebenzi wentliziyo nemiphunga: uxinzelelo oluphantsi noxhathiso oluphantsi nangona isixa segazi esimpontshwa yintliziyo sigciniwe. Ubungqina bezilingo ezinolwabiwo olungakhethiyo bokunyanga ivasoplegia esele ikhona buxhomekeke ikakhulu kulingo olunye oluncinane. Ezinye izilingo ezimbini zavavanya imethylene eluhlaza okwesibhakabhaka ngaphambi okanye ngexesha lotyando ukuthintela ivasoplegia, nto leyo engumbuzo wekliniki owahlukileyo.
Kwilingo likaLevin noogxa bakhe elinolwabiwo olungakhethiyo lwevasoplegia esele ikhona emva kotyando, izigulana ezingama-56 zabelwa ukuba zifumane i-1.5 mg/kg efakwa emthanjeni kwisithuba seyure enye okanye iplacebo. Ivasoplegia yaphela ngokukhawuleza kwiqela elanyangwayo, ngoxa izigulana ezi-8 kwezingama-28 ezifumene iplacebo zaqhubeka zinevasoplegia ngaphaya kweeyure ezingama-48, kwaye ukufa kwakuyi-0 kwezingama-28 xa kuthelekiswa ne-6 kwezingama-28. Isiphumo sokupheliswa komothuko siyaphawuleka, kodwa izigulana ezingama-56 azinakuqinisekisa isiphumo ekusindeni, kwaye umahluko ekufeni awomelelanga ngokwaneleyo ukuba ungasetyenziswa ngokubanzi.
Izilingo zokuthintela zibonisa iziphumo ezixubeneyo. Kuphononongo lukaOzal noogxa bakhe lwezigulana ezisemngciphekweni ophezulu zotyando lokudlulisela igazi ngaphaya kwemithambo yentliziyo evalekileyo, ukufakwa emthanjeni ngaphambi kotyando kwanciphisa ivasoplegia ukusuka kwi-13 kwezingama-50 ukuya kwi-0 kwezingama-50. UMaslow noogxa bakhe bafumana isiphumo esihlala ixesha elifutshane ngakumbi ngexesha lotyando xa kusetyenziswa umatshini othatha umsebenzi wentliziyo nemiphunga, ngoxa uCho noogxa bakhe bengafumananga nzuzo ibonakalayo ekuhambeni kwegazi okanye kumayeza anyusa uxinzelelo lwegazi. Ukuthintela kwizigulana zotyando ezikhethiweyo nokunyanga ivasoplegia esele ikhona kufanele kuthathwe njengamabango ahlukeneyo axhaswa bubungqina obahlukileyo.
Umothuko we-sepsis
Umothuko we-sepsis udibanisa usulelo nokungasebenzi kakuhle kokujikeleza kwegazi okuqhubekayo emva kokunikwa ulwelo, ngoko inorepinephrine iba sisiseko sokhathalelo, kwaye izilingo zibuza ukuba imethylene eluhlaza okwesibhakabhaka iyalinciphisa na ixesha lokufumana iicatecholamine. Umqondiso wobungqina uhambelana ngakumbi kunakutyando kodwa usahluka, kwaye uphathelele ukunciphisa ukusetyenziswa kwamayeza anyusa uxinzelelo lwegazi kunokusinda.
Olona lingo lukhulu lwakutshanje luphononongo luka-Ibarra-Estrada noogxa bakhe luka-2023 olunolwabiwo olungakhethiyo lwemethylene eluhlaza okwesibhakabhaka eyongezwa kunyango kwangethuba, apho abantu abadala abangama-91 abafakwe kuhlalutyo bafumana ukufakwa emthanjeni kangangeeyure ezintandathu ngosuku, kwiidosi ezintathu, okanye iplacebo ehambelanayo, ukongeza kwinorepinephrine, ihydrocortisone, nevasopressin xa kufuneka. Ixesha eliphakathi ngokolungelelwano de kuyekwe amayeza anyusa uxinzelelo lwegazi laliyi-69 yeeyure xa lithelekiswa ne-94 yeeyure, ngoxa ukufa nexesha lokuncediswa ngokuphefumla zazifana. Izilingo zangaphambili zazincinane: ulingo lokuqala lukaKirov noogxa bakhe lwezigulana ezingama-20 lwabonisa ukuncipha okukhulu kweecatecholamine nge-bolus ye-2 mg/kg elandelwa kukufakwa emthanjeni okwandiswayo, kwaye uMemis noogxa bakhe bafumana uxinzelelo oluyi-avareji kwimithambo ehambisa igazi lisuka entliziyweni oluphezulu emva kokufakwa emthanjeni (85 xa kuthelekiswa ne-74 mmHg), ngaphandle komlinganiselo wokunciphisa amayeza anyusa uxinzelelo lwegazi. Ngokuchaseneyo nezi ziphumo, ulingo lukaDong noogxa bakhe lwezigulana ezingama-72 olulawulwa ngeplacebo alufumananga nzuzo ibalulekileyo kwinorepinephrine okanye kuxinzelelo, kwaye olunye uthelekiso lwafumanisa ukuba ivasopressin yayingcono kunemethylene eluhlaza okwesibhakabhaka njengeyeza lesibini lokunyusa uxinzelelo lwegazi kwiiyure ezili-12 nezingama-24. Umsebenzi wokufumana idosi efanelekileyo owenziwa nguJuffermans noogxa bakhe wabonisa ukuba uxinzelelo noxhathiso luyenyuka njengoko idosi isanda, kodwa ukuhanjiswa kwegazi kumalungu angaphakathi esisu okuphazamisekileyo kwakuyinkxalabo kwi-7 mg/kg.
Itheyibhile yezilingo
I-IV ithetha ukufakwa emthanjeni. I-NE ithetha inorepinephrine. I-MAP ithetha uxinzelelo oluyi-avareji kwimithambo ehambisa igazi lisuka entliziyweni. I-SVR ithetha uxhathiso lwemithambo yegazi emzimbeni wonke. Umqolo ngamnye ubonisa into eyanikwa izigulana kuphononongo, hayi isincomo sonyango.
| Ulingo nemeko | Indlela yokunikwa | Isiphumo kumayeza anyusa uxinzelelo lwegazi | Isiphumo ekuhambeni kwegazi | Ukufa | Iziganeko ezingathandekiyo |
|---|---|---|---|---|---|
| Levin 2004: ivasoplegia esele ikhona emva kotyando lwentliziyo, 28 xa kuthelekiswa nama-28 | 1.5 mg/kg IV kwisithuba seyure e-1 | Ivasoplegia yaphela kuzo zonke izigulana ezanyangwayo kwiiyure ezi-6; ezi-8 kwezingama-28 kwiqela lolawulo zaqhubeka zichaphazelekile ngaphaya kweeyure ezingama-48 | Ukubuyela ngokukhawuleza kwe-MAP ne-SVR kwiqela elanyangwayo | 0 kwezingama-28 xa kuthelekiswa ne-6 kwezingama-28; luncinane kakhulu ukuqinisekisa isiphumo ekusindeni | Akukho mqondiso mkhulu wetyhefu uxeliweyo ngale ndlela yokunikwa |
| Ozal 2005: ukuthintela kwizigulana ezi-100 ezisemngciphekweni ophezulu zotyando lokudlulisela igazi ngaphaya kwemithambo evalekileyo, 50 xa kuthelekiswa nama-50 | Isisombululo se-1 pesenti esifakwa emthanjeni ukususela kwiyure e-1 ngaphambi kotyando | Ivasoplegia kwi-0 kwezingama-50 xa kuthelekiswa ne-13 kwezingama-50; ukuthintela, hayi ukunyanga esele ikhona | Uxinzelelo oluphezulu ngexesha lotyando kwiqela elanyangwayo | Yayingelolingo lokufa | Akukho mqondiso mkhulu wetyhefu uxeliweyo |
| Cho: imethylene eluhlaza okwesibhakabhaka yokuthintela kutyando lwentliziyo | Ukufakwa emthanjeni ngexesha elijikeleze utyando | Akukho mahluko ubalulekileyo kumayeza anyusa uxinzelelo lwegazi | I-MAP ne-SVR azizange zahluke ngokubalulekileyo | Yayingelolingo lokufa | Akukho zinga leziganeko ezingathandekiyo lixeliweyo ngokukhethekileyo |
| Kirov 2001: ulingo lokuqala lomothuko we-sepsis, 10 xa kuthelekiswa ne-10 | I-bolus ye-2 mg/kg, ilandelwe kukufakwa emthanjeni okwandiswa ngokwamanqanaba ukuya kwi-5.75 mg/kg iyonke | I-NE yancipha ukuya kuma-87 epesenti; iepinephrine yehla ngama-81 epesenti; idopamine yehla ngama-40 epesenti | I-MAP yayiphezulu ngokubalulekileyo kwiiyure ezi-6 nezingama-24 | Ukufa kwiintsuku ezingama-28 kwakuyi-5 kwezili-10 xa kuthelekiswa ne-7 kwezili-10; yayingelolingo lokufa | Umchamo oluhlaza okwesibhakabhaka nokutshintsha kombala wolusu; akukho mqondiso mkhulu wetyhefu kumalungu omzimba |
| Memis 2002: isepsis eqatha, 15 xa kuthelekiswa ne-15 | 0.5 mg/kg ngeyure kwiiyure ezi-6 | Akukho mlinganiselo wobungakanani bokunciphisa amayeza | I-MAP emva kokufakwa emthanjeni yayiyi-85 xa kuthelekiswa ne-74 mmHg | Lwalungenawo amandla aneleyo ovavanyo lokufa | Akukho mqondiso mkhulu wetyhefu uxeliweyo |
| Ibarra-Estrada 2023: umothuko we-sepsis, abangama-91 bahlalutywa | Ukufakwa emthanjeni kangangeeyure ezintandathu ngosuku kwiidosi ezintathu | Ixesha eliphakathi ngokolungelelwano de kuyekwe amayeza anyusa uxinzelelo lwegazi laliyi-69 xa lithelekiswa ne-94 yeeyure | Uxinzelelo lwalulawulwa ukuya kwinqanaba ekujoliswe kulo kuwo omabini amaqela | Ukufa kwakufana kumaqela omabini | Umchamo oluhlaza okwesibhakabhaka okanye oluhlaza wawuqhelekile; ukusilela kwe-G6PD nokusetyenziswa kwe-SSRI kutshanje kwakuzizizathu zokungabandakanywa |
| Dong 2025: umothuko we-sepsis kwizigulana ezincediswa ngokuphefumla, 36 xa kuthelekiswa nama-36 | 2 mg/kg kwisithuba semizuzu eli-15 kunye ne-1 mg/kg kwisithuba seeyure ezili-12 | Umahluko kwi-NE wawukufutshane noziro; akukho mahluko kwixesha de kuyekwe amayeza anyusa uxinzelelo lwegazi | Umahluko kwi-MAP wawungu-minus 1.2 mmHg, ungenakubaluleka ngokweenkcukacha-manani; ukuhamba kwegazi kwimithambo emincinane kwaphucuka | Ukufa kwiintsuku ezingama-28 kwakuyi-9 kwezingama-36 xa kuthelekiswa ne-15 kwezingama-36, kungabalulekanga ngokweenkcukacha-manani | Umchamo oluhlaza okwesibhakabhaka okanye oluhlaza kuzo zonke izigulana ezanyangwayo; akukho mqondiso wengxaki kwisibindi, kwizintso, okanye ekufumaneni ioksijini |
Ngaba kukho into apha ebonisa ukufa kwabambalwa?
Uhlalutyo oludibanisa izilingo lubonakale luneziphumo ezilunge ngakumbi kunezilingo ngazinye, kodwa uqikelelo olulungileyo luba buthathaka xa luhlolisiswa. Uhlalutyo luka-2024 oludibanisa izilingo ezintandathu zomothuko we-sepsis lwafumana umlinganiselo womngcipheko wokufa kwixesha elifutshane oyi-0.66, kodwa isiphumo sayeka ukubaluleka ngokweenkcukacha-manani xa izilingo ezinomngcipheko ophezulu wokuthambekela zazingabandakanywa. Olona hlalutyo lwakutshanje oludibanisa kuphela izilingo ezilawulwayo ezinolwabiwo olungakhethiyo (RCT), oluquka izilingo ezisithoba nezigulana ezingama-535, lwafumana umlinganiselo we-odds wokufa kwiintsuku ezingama-28 ukuya kwezingama-30 oyi-0.73, onesithuba sokuzithemba esisuka kwi-0.40 ukuya kwi-1.36, ongabalulekanga ngokweenkcukacha-manani. Uhlalutyo lwalo olulandelelanayo lwezilingo lwaqikelela ukuba kuya kufuneka izigulana eziyi-1,773 endaweni yamakhulu ambalwa afumanekayo. Isishwankathelo esinyanisekileyo sesokuba inzuzo ekusindeni ayikaqinisekiswa, hayi ukuba iboniswe ukuba ayikho.
Amanqaku okhuseleko avela kubungqina basesibhedlele
Iziphumo eziqhelekileyo kwizilingo yayingumchamo oluhlaza okwesibhakabhaka okanye oluhlaza nokutshintsha kombala wolusu, kunye nokunyuka okuncinane kwemethemoglobin. Imingcipheko enzulu ivela kulwazi lwemveliso evunyelweyo yokufakwa emthanjeni kunokuba ivele kumanani eziganeko kwizilingo: isindromu yeserotonin xa idityaniswe namayeza achaphazela iserotonin okanye iiopioid, ukungavumeleki kokusetyenziswa kubantu abaswele i-G6PD ngenxa yomngcipheko wokonakala kweeseli ezibomvu zegazi, ukufundwa okuphantsi ngokungeyonyaniso sisixhobo esilinganisa ioksijini egazini sisebenzisa ukubetha kwemithambo ngexesha nangokukhawuleza emva kokufakwa emthanjeni, kunye noxinzelelo lwegazi oluphezulu oluxeliweyo njengesiphumo esingathandekiyo. Izilingo ezininzi zakutshanje azizange zibandakanye izigulana eziswele i-G6PD okanye ezazifumene kutshanje amayeza achaphazela iserotonin, ngoko iitheyibhile zazo zokhuseleko ezingenazingxaki azilinganisi umngcipheko kuloo maqela. Obu bungqina bukwafanele bufundwe kunye nesishwankathelo esibanzi sokusetyenziswa kwekliniki kunye novavanyo lokhuseleko; abafundi abangaqhelananga nendlela izilingo ezilungiselelwa ngayo banokuqala ngesikhokelo sokufunda uphando lwemethylene eluhlaza okwesibhakabhaka.
Ivasoplegia nomothuko we-sepsis zisenokufuna uphengululo olunzulu olwahlukeneyo ukuba ubungqina buyanda, kodwa uncwadi olukhoyo ngoku lufanele uphengululo olunye lokhathalelo lwezigulana ezikwimeko emaxongo: isiphumo sokwenene sokucutha imithambo yegazi nokunciphisa ukusetyenziswa kwamayeza anyusa uxinzelelo lwegazi, esicace kakhulu kwivasoplegia esele ikhona nakumothuko we-sepsis kwangethuba, ngaphandle kwenzuzo ebonisiweyo ekusindeni kunye nemida yokhuseleko engabandakanyi amaqela athile ezigulana. Nabani na ojongene nezi meko sele ekukhathalelo olunzulu, kwaye imethylene eluhlaza okwesibhakabhaka kule meko sisigqibo seyunithi yokhathalelo olunzulu (ICU) esenziwa liqela elinyangayo, hayi unyango lwasekhaya olucingelwe ngokusekelwe ekufakweni kwayo emthanjeni esibhedlele.