I-methylene blue ekuhlinzweni nasezinqubweni zokuxilonga: ukudweba imephu, ukuhlola ukuvuza, nokulandela ngomdayi

Isiguli esilungiselela ukuhlinzwa ibele sifunda ukuthi “umdayi oluhlaza okwesibhakabhaka” uzodweba imephu yezindlala zaso ze-lymph. Isihlobo esihlolelwa i-fistula sizwa nge-“fistulography” bese sicabanga ukuthi kuzohileleka umdayi. Umuntu one-tracheostomy unikezwa “ukuhlolwa ngomdayi oluhlaza okwesibhakabhaka” ukuze kuhlolwe ukuphepha kokugwinya. Bobathathu bezwa amagama athi oluhlaza okwesibhakabhaka bese becabanga ukuthi kuyinqubo efanayo esebenzisa umdayi ofanayo. Akunjalo.

I-methylene blue egumbini lokuhlinzela iqondakala kangcono njengomqondo owodwa osetshenziswa ezindaweni ezingahlobene: umdayi owenza okungabonakali kubonakale. Ilandela ukugeleza koketshezi lwe-lymph, ifake umbala endlaleni okuhloswe kuyo, ifake umbala oketshezini lokuhlola oluvuzayo, imake ikhafu yomgudu womoya edabukile, noma iveze ukuxhumana okufihlekile phakathi kwemigodi emibili yomzimba. Ubufakazi, inani elisetshenziswayo, nobungozi kwehluka kakhulu phakathi kwalokhu kusetshenziswa. Futhi ezinye izinqubo ezibizwa ngokuthi “ukuhlolwa ngomdayi oluhlaza okwesibhakabhaka” zisebenzisa abanye odayi ngokuphelele, kanti i-fistulography eyenziwa ngokuthwebula izithombe ayisebenzisi nhlobo i-methylene blue. Lesi sihloko sichaza ukusetshenziswa ngakunye ngokwehlukana. Ngombuzo obanzi wokuthi yikuphi ukusetshenziswa kwezokwelapha okuqinisekisiwe nokuthi yikuphi okusaphenywa, bheka ukusetshenziswa kwezokwelapha okugunyaziwe nokusaphenywa.

Imephu yezinqubo: ukwenza kubonakale, hhayi ukwelapha

Akukho kulokhu okuwukwelapha nge-methylene blue. Ukusetshenziswa kokwelapha ngomjovo emthanjeni okugunyazwe kulebula e-United States kungokwe-methemoglobinemia etholakala ngokuhamba kwesikhathi, ngokuvamile ngo-1 mg/kg IV, njengoba kushiwo emininingwaneni ye-DailyMed yokunikeza umuthi. Ukusetshenziswa kokulandela ekuhlinzweni kuvame ukuba ngaphandle kokugunyazwe kulebula noma kuncike kudivayisi ethile, kusetshenziswa leyo mfanelo efanayo yokufaka umbala.

Ukuthatha isampula yendlala ye-lymph ye-sentinel: ukulandela ukugeleza

Ngemva kokujovwa endaweni ethile eduze kwesimila, i-methylene blue ingena emithanjeni ye-lymph bese ifaka umbala oluhlaza okwesibhakabhaka emigudwini okudlula kuyo uketshezi nasezindlaleni zokuqala (ze-sentinel), ukuze udokotela ohlinzayo akwazi ukuzihlonza ngokuzibona. Kumdlavuza webele, umdayi oluhlaza okwesibhakabhaka usalokhu ungumaka oqinisekisiwe, obuvame ukuhlanganiswa ne-radiocolloid ye-technetium-99m, futhi iziqondiso zamanje ze-NICE zincoma indlela ehlanganisa i-isotope nomdayi oluhlaza okwesibhakabhaka. Qaphela ukuthi “umdayi oluhlaza okwesibhakabhaka” eziqondisweni awusho njalo i-methylene blue ngokuqondile; i-patent blue V ne-isosulfan blue nazo ziyasetshenziswa.

Izindlela ezivamile zokuhlinzwa kwebele zisebenzisa i-methylene blue engu-1% (10 mg/mL), ngokuvamile cishe u-1 mL, kanti indawo yokujova ingaba ngaphansi kwengxenye emnyama ezungeze ingono, eduze kwayo, ngaphakathi kwesikhumba, noma eduze kwesimila. Ukudweba imephu nge-methylene blue kuphela kuyasebenza, kodwa ubufakazi obuhlanganisiwe busekela ukufakwa komaka okhipha imisebe: ukuhlaziywa okuhlanganisa izifundo eziningi nge-methylene blue kuphela kwabika izinga lokuhlonza elingu-91% kanye nezinga lemiphumela ekhombisa ukungabi khona kwenkinga ngokungeyikho elingu-13%, kuyilapho izindlela ezihlanganisiwe zihlonza ngokuthembeka okukhulu. Ku-melanoma, ukudweba imephu kuncike ngokuyinhloko ekuthwebuleni ukugeleza kwe-lymph nge-technetium ngaphambi kokuhlinzwa, kusetshenziswa umhloli wemisebe ye-gamma ngesikhathi sokuhlinzwa, kanti umdayi oluhlaza okwesibhakabhaka uyisengezo; iziqondiso zobuchwepheshe ze-ASCO/SSO zichaza ukujovwa kuka-1–2 mL womdayi oluhlaza okwesibhakabhaka ofanele izicubu eziphilayo ngaphakathi kwesikhumba, kulindwe cishe imizuzu engu-5–10 ukuze uhambe ngemithambo ye-lymph, futhi zibala i-methylene blue ne-isosulfan blue njengezinketho.

Indlela entsha yokudweba imephu ngokukhanya kwe-fluorescence nge-indocyanine green (ICG) yenza imithambo ye-lymph ibonakale ngesikhathi sangempela ngaphandle kwemisebe eyenza ama-ion, kodwa idinga imishini yokukhanya okusondele ku-infrared, futhi ukwamukelwa kwayo eziqondisweni kusahluka. Incazelo esebenzayo: i-methylene blue ingumaka oshibhile noqondakala kalula ngokubukwa, kanti ubuthakathaka bayo ukuthi izindlala zibonakala kuphela lapho seziveziwe ngokuhlinzwa.

I-methylene blue inezinkinga ezithile lapha. Ingabangela ukuhlala kombala esikhumbeni nasezicutshini isikhathi eside, izinguquko zokuvuvukala, ukufa kwezicubu zamafutha, futhi ngezinye izikhathi ukufa kwezicubu zesikhumba; izithombe zebele ezithathwa ngemva kokuhlinzwa zingabonisa izilonda ezinesimo esingajwayelekile ezihlobene nomdayi, ezibukeka njengokubuya kwesifo. Odokotela abahlinzayo kufanele bazise abezokuthwebula izithombe zezokwelapha nabezokuhlola izicubu njalo lapho umdayi ujovwe ngaphakathi noma eduze kwesampula. Odayi abaluhlaza okwesibhakabhaka bangabangela nokungezwani okusheshayo; ukuhlaziywa okuhlanganisa izifundo zezinqubo zezindlala ze-sentinel ezingaphezu kuka-60,000 kwathola izinga eliphelele lokungezwani okubucayi, i-anaphylaxis, okubangelwa umdayi oluhlaza okwesibhakabhaka elingaba ngu-0.061%, kanti i-methylene blue yayihlobene namazinga aphansi kune-isosulfan blue. Imininingwane ebanzi yokuphepha iqoqwe kwesithi imiphumela engemihle nokuphepha.

Ukuthola indawo yezindlala ze-parathyroid: ukusetshenziswa okudala okusakazeka emzimbeni, manje okukhethwa ezimweni ezithile

Ukufakwa kwe-methylene blue emthanjeni ukuze kutholakale izindlala ze-parathyroid ezingajwayelekile kuyindlela endala esaqhubeka kuphela njengesengezo ezimweni ezikhethiwe. Ngokomlando, imithamo emikhulu ngokulingene yayifakwa emthanjeni ngaphambi kokuhlola intamo ngokuhlinzwa ukuze izicubu ezingajwayelekile zibe luhlaza okwesibhakabhaka; izindlela ezishicilelwe zisukela cishe ku-3 kuya ku-7.5 mg/kg IV. Ukubuyekezwa okuhlelekile kwathola izifundo zokubheka ezingu-39 kodwa akukho zilingo ezinokwabiwa okungahleliwe: kubikwe ukuthi amazinga okufakwa kombala ayephezulu, kodwa kwakungakaqinisekiswa ukuthi kunezela inzuzo lapho kusetshenziswa kanye nezindlela zanamuhla zokuthola indawo.

Ukwenza kwamanje kuncike kunalokho ku-ultrasound nezinye izindlela zokuthwebula izithombe ngaphambi kokuhlinzwa, ekwakhekeni komzimba okubonakala ngesikhathi sokuhlinzwa, nasekuqapheni ihomoni ye-parathyroid ngesikhathi sokuhlinzwa. Isiqondiso se-AAES sibala i-methylene blue phakathi kwezingezo eziningana ezingasetshenziswa ukwenza izinto zibonakale, kunokuba ibe indlela eyinhloko yokuthola indawo.

Lokhu futhi kuwukusetshenziswa lapho isixwayiso sokusebenzisana kwemithi sibaluleke khona kakhulu. I-methylene blue iyisivimbeli esinamandla se-monoamine oxidase esinomphumela ongaguqulwa, futhi ukubuyekezwa okuhlelekile kwabika ukulimala kwesimiso sezinzwa ezigulini ezingu-25, zonke ezazithatha imithi ethinta i-serotonin. Ukubuyekezwa okuhlukile kwezincwadi zocwaningo nge-serotonin syndrome ehlobene ne-methylene blue kwathola izehlakalo ezingu-50, zonke zihilela imithi yokudangala ethinta i-serotonin, iningi lihlobene nokuhlinzwa kwe-parathyroid noma ukwelashwa kwe-vasoplegia. Imithamo ye-parathyroid eyayisetshenziswa ngokomlando ingaba ngaphezu kakhulu komthamo wokwelapha wamanje ongu-1 mg/kg, ngakho lokhu kusebenzisana kuhlobene nokuchayeka okusakazeka emzimbeni, hhayi nethonsi lomdayi esicutshini.

Kuchazwe indlela ehlukile enokuchayeka okuncane kakhulu ezintanyeni ezihlinzwa futhi noma ezinezibazi: ukujova okuqondiswa nge-ultrasound ngokuqondile endaweni eyaziwayo okuhloswe kuyo, lapho amaqembu amancane asebenzisa cishe u-0.2 mL wengxube engu-1% ehlanjululwe ngesilinganiso esingu-1:5 (cishe u-0.2%) ngaphambi nje kokuhlinzwa. Ubufakazi bukhawulelwe emaqenjini amancane ocwaningo lokubheka.

Ukuhlolwa ngomthwalo wamanzi anosawoti: umdayi awuwona owenza ukuhlolwa kusebenze

Ekuhlolweni ngomthwalo wamanzi anosawoti ukuze kutholakale ukuthi ukulimala kuvule ilunga yini, amanzi anosawoti ajovwa elungeni bese kubhekwa ukuthi uketshezi luyavuza yini enxebeni. Ngezinye izikhathi i-methylene blue iyafakwa ukuze nje kwenziwe uketshezi oluphumayo lubonakale kalula. Okutholakele okubalulekile ukuthi umdayi awukakhonjiswa ukuthi uthuthukisa ukuhlolwa: ocwaningweni lwamadolo lweziguli ezingu-58, olwaluhlelwe kusengaphambili futhi lwabela izindlela ngokungahleliwe, amazinga emiphumela ekhombisa ukungabi khona kwenkinga ngokungeyikho ayengu-69% nge-methylene blue uma eqhathaniswa no-66% ngamanzi anosawoti angenamdayi, futhi kwakudingeka amanani oketshezi afanayo ukuze ukuhlolwa kubonise ukuvuza. Ukubuyekezwa okuhlelekile kwango-2025 kwathola ukuthi izifundo ezingu-8 kwezingu-23 zokuhlolwa ngomthwalo wamanzi anosawoti zazisebenzise umdayi, kodwa ukusebenza kokuhlolwa kwakuncike elungeni, endaweni yenxeba, enanini elijoviwe, nasendleleni esetshenzisiwe kunasekufakweni komdayi. Alikho izinga lokugxila elijwayelekile eliqinisekisiwe lale njongo. I-methylene blue lapha iyinto yokufaka umbala engakhethwa ezindleleni zomlando noma zokuhlola, hhayi ingxenye eyenza ukuhlolwa kukwazi ukubona inkinga.

Amashubhu emigudu yomoya e-laser: umdayi ovalelwe ngaphakathi kwekhafu

Lokhu kusetshenziswa kwehluka kukho konke okunye okukuleli khasi: umdayi ngokuvamile ufakwa ngaphakathi kwekhafu yeshubhu elifakwa emqhoqhoqho, hhayi esigulini. Ekuhlinzweni kwemigudu yomoya nge-laser, iziqondiso zokuphepha emlilweni ngesikhathi sokulalisa isiguli zincoma ishubhu elifanele elimelana ne-laser futhi, lapho kungenzeka khona, ukugcwalisa ikhafu ngamanzi anosawoti kunomoya. Ukufaka umbala kula manzi anosawoti nge-methylene blue kusho ukuthi ukubhoboza kwe-laser kubangela ukuvuza okuluhlaza okwesibhakabhaka okubonakala ngokushesha. Alikho izinga lokugxila elibekwe njengelisebenza kuyo yonke indawo; inhloso ukwenza umbala ubonakale, njengoba kuchazwe eselulekweni se-ASA sokusebenza mayelana nemililo emagumbini okuhlinzela.

Kunezixwayiso ezimbili ezibalulekile. Amanye amashubhu e-laser akudala ayefaka amakristalu omdayi ekhafuni noma ohlelweni lokuyigcwalisa, futhi umbiko oshicilelwe uchaza isigameko samakristalu angancibilikile avala ishubhu lokugcwalisa kangangokuthi ikhafu ayikwazanga ukukhishwa umoya; yingakho imiyalelo yedivayisi ethile ibalulekile. Futhi i-methylene blue ngokwayo ayenzi ishubhu elijwayelekile limelane ne-laser; ukuvimbela umlilo kuncike nasekwakhiweni kweshubhu, ekuvikeleni ikhafu, nasekunciphiseni ukugcwala kwezinto ezisekela ukusha.

Ukuhlola ukugwinya: “umdayi oluhlaza okwesibhakabhaka” ungase ungabi yi-methylene blue

Ekuhlolweni okuvamile okwenziwa eceleni kombhede wesiguli esine-tracheostomy, ukudla noma uketshezi kufakwa umbala bese kuhlolwa amafinyila omqhoqhoqho ukuthi anombala oluhlaza okwesibhakabhaka yini; umphumela obonisa lo mbala usekela ukuthi ukudla noma uketshezi lungene emgudwini wokuphefumula. Amagama asetshenziswayo angadidanisa kalula: izindlela ezishicilelwe “zokuhlolwa ngomdayi oluhlaza okwesibhakabhaka” nezokuhlolwa okuguquliwe ngomdayi we-Evans blue zisebenzise i-Evans blue, i-methylene blue, nodayi bokudla, ngakho “ukuhlolwa ngomdayi oluhlaza okwesibhakabhaka” akusho ngokuzenzakalelayo i-methylene blue.

Inkinga enkulu yimiphumela ekhombisa ukungabi khona kwenkinga ngokungeyikho. Ukuzwela kokuhlolwa ezindleleni ezahlukene kusukela cishe ku-38% kuya ku-95%, futhi iziqondiso zibheka ukuhlolwa ngokuyinhloko njengesengezo esisekela ukuba khona kwenkinga lapho umphumela ubonisa umbala: umphumela ongabonisi umbala awukukhiphi ukungena kokudla noma uketshezi emgudwini wokuphefumula. Ukuhlola okuqinisekisayo, lapho kudingeka, kusebenzisa ukuhlola ngemishini, njengokuhlola ukugwinya nge-endoscope enomucu wokukhanya noma nge-videofluoroscopy. Alikho inani lomdayi elifanele kakhulu eliqinisekisiwe.

Ungakudidanisi lokhu nomkhuba wakudala wokufaka umbala ngokuqhubekayo ekudleni okunikezwa ngomgudu wokugaya kusetshenziswa i-FD&C Blue No. 1. Lowo umdayi ohlukile nomkhuba ohlukile, owawuhlotshaniswa nokumuncwa kusakazeke emzimbeni kanye nobuthi obukhulu ezigulini ezigula kakhulu, futhi kamuva kwelulekwa ukuba ungabe usetshenziswa.

Ukulandela i-fistula akuyona i-fistulography

Ukulandela endaweni ethile nge-methylene blue ne-fistulography eyenziwa ngokuthwebula izithombe kuyizindlela zokuxilonga ezihlukile ezivame ukudidaniswa. Ekulandeleni endaweni ethile, umdayi ufakwa embotsheni okusolwa ukuthi eye-fistula noma emgodini wesitho, bese uchwepheshe wezokwelapha ebheka ukuthi okuluhlaza okwesibhakabhaka kuvela kwenye indawo yini noma alandele izicubu ezifakwe umbala ngesikhathi sokuhlinzwa: ukujova ngembobo yangaphandle ukuze kutholakale umzila we-fistula yasendunu, ukufaka umbala oketshezini lokugeza isinye ukuze kuvezwe ukuvuza okuya esithweni sangasese sowesifazane lapho kusolwa i-fistula phakathi kwesinye naleso sitho, kanye nokunye ukusetshenziswa okufanayo okuncike endaweni ethile. Izindlela zincike endaweni, futhi amazinga okugxila awamisiwe abe yizinga elivamile.

I-fistulogram noma i-sinogram yangempela iyinqubo yokuthwebula izithombe: into ebonakala kuma-X-ray ijovwa emzileni bese i-fluoroscopy noma i-CT idweba imephu yokwakheka kwawo. Akukhona ukuhlolwa nge-methylene blue. Ayikho kulezi zindlela ethatha indawo ye-MRI, i-CT, i-endoscopy, noma ukuhlolwa isiguli silalisiwe lapho i-fistula iyinkimbinkimbi.

Iphutha elilodwa elincike endleleni yokufaka lifanele ukugcizelelwa: i-methylene blue efakwe ngengxenye yokugcina yethumbu ingamuncwa bese kamuva ikhishwa emchameni. Ucwaningo lwamavolontiya lwabonisa lokhu ngemva kokufakwa kwengxube engu-50-mg nge-enema, futhi lwaphetha ngokuthi umdayi ofakwe ngaphakathi engxenyeni yokugcina yethumbu akufanele usetshenziselwe ukuqinisekisa i-fistula esolwayo phakathi kwethumbu elikhulu nesinye, ngoba umchamo oluhlaza okwesibhakabhaka ungavela ngaphandle kokuba khona kwanoma iyiphi i-fistula. Chaza indawo emzimbeni nendlela yokuthwebula izithombe kunokuthatha yonke imibuzo ye-fistulography njengokuhlolwa okufanayo.

Imikhawulo ehlanganyelwa yilezi zindlela okufanele ikhunjulwe

Ukuchayeka okusakazeka emzimbeni kudinga ukucabangela indlela umuthi osebenza ngayo, okungekho ekulandeleni endaweni ethile. Uma i-methylene blue isanele egazini, imunca ukukhanya okusetshenziswa yimishini yokuqapha, ngakho ukukala umoya-mpilo egazini nge-pulse oximetry kungabonisa izinga eliphansi kunelangempela. Ukunikezwa kwayo ngendlela esakazeka emzimbeni kungabangela ukubhidlika okukhulu kwamangqamuzana abomvu egazi kubantu abanokushoda kwe-G6PD, futhi ilebula yamanje yohlobo olujovwayo ibala ukushoda kwe-G6PD njengesizathu sokungawusebenzisi. Futhi, ubungozi obuvela emijovweni emincane kakhulu endaweni ethile noma emdayini ovalelwe ngaphakathi kwekhafu yomgudu womoya abufani nobama-mg/kg amaningana afakwe emthanjeni, kodwa ukuthi “endaweni ethile” akusho ngokuzenzakalelayo ukuthi akukho okumuncwa kusakazeke emzimbeni: indlela yokufaka, inani, nokungonakali kwezicubu kubalulekile.

Iphuzu lokugcina limayelana nokuthi umdayi uyini ngempela. Ukwenza izinto zibonakale ekuhlinzweni kuncike ekwazini ngokuqondile ukuthi yimuphi umdayi osesirinjini: i-methylene blue, i-isosulfan blue, i-patent blue V, i-Evans blue, nodayi bokudla basebenza ngokwehlukile futhi banobungozi obuhlukile, kodwa bonke bavela ezinqubweni ezibizwa ngokunganaki ngokuthi ukuhlolwa “ngomdayi oluhlaza okwesibhakabhaka”. Ukunakekela okufanayo kuyadingeka nangaphandle kwesibhedlela. Imikhiqizo ethengiswa njenge-methylene blue yehluka kakhulu ngezinga nangemibhalo ehambisana nayo, futhi into yezinga lokudaya izindwangu ayithathi indawo yento ekhiqizwe yahlolwa ukuze isetshenziselwe injongo eshiwo. Lapho ubumsulwa bubalulekile, bheka ukukhiqizwa ngokwezinga lemithi, ukuhlolwa okuphelele kwe-USP okunesitifiketi sokuhlaziywa seqoqo elithile, kanye nokuqinisekiswa okuzimele kunokuhlolwa kwezinsimbi ezisindayo kuphela. Umhlahlandlela wokufunda isitifiketi sokuhlaziywa uchaza ukuthi yimiphi imikhakha okufanele uyihlole. Imithombo ejulile ibalwe emtatsheni wocwaningo.