血液灌流抢救儿童急性中毒35例报告

Effect of hemoperfusion in treatment of children with acute poisoning

目的本研究观察血液灌流（Hemoperfusion，HP）治疗中毒的效果，组织毒物再释放时间，HP和非lip期的毒代动力学，HP对血细胞和血生化的影响，儿童HP中应用肝素剂量和血流量等。方法35例中毒儿童[男26例，女9例，年龄10个月～13岁，平均年龄（3．35±2．50）岁]接受HP治疗1～3次，其中12例2次，4例3次。收集氟乙酰胺（FAM）中毒6例和毒鼠强（TET）中毒10例病人血2ml，用气相色谱法（GC法）检测毒物浓度。结果HP后所有病例中毒症状缓解或明显减轻，27例（77％）中毒儿童治愈，6例（17％）好转，2例（6％）死因多脏器衰竭。4例已缓解的病例在HP后6-24h症状反复，其中FAM 1例，TET 3例。HP后血小板、红细胞和血红蛋白降低，P〈0．05；HP前后WBC、血清丙氨酸氨基转移酶（ALT）、天门冬氨酸氨基转移酶（AST）、肌酸激酶（CK）、肌酸激酶同工酶（CK-MB）、尿素氮（BUN）、肌酐（CRE）和总白（TP）、总白（ALB）、球蛋白（GLO）等值比较无显著差异性，P〉0．05。检测FAM和TET中毒儿童在HP前，HP治疗60、120min FAM量（ng／ml）分别是309．00±114．75，254．67±128．15和230．00±107．53，χ^2=7．000，df=2，P〈0．030；TET量（ns／ml）分别是216．10±59．07，176．20±47．30和161．00±31．49，χ^2=13．400，df=2，P=0．001。HP1h较HP前下降值FAM是54．33（17．58％），TET是39．9（18．46％），HP2h较HP1h下降FAM是24．67（7．98％），TET是15．2（7．03％），HP2h使FAM和TET浓度下降25．57％和25．50％，HP第1小时下降速度快于第2小时；HP后2～6h，4例（FAM1例，TET3例）已降低的毒物血浓度回升，但低于HP前水平；FAM和TET的t1/2在HP期和非HP期分别为（2．40±0．66）h，（15．60±8．22）h和（4．10±1．66）h，（67．01±48．42）h。HP首次肝素平均剂量（0．54±0．15）mg／kg；每30min追加（0．20±0．06）mg／kg；血流量（4．39±0．99）ml／min。结论HP使毒物代谢消除t1/2明显缩短，能安全、有效地治疗中毒患者；HP后2～6h部分患者血浓度可能有短暂性回升；活性炭HP不能吸附与血浆白蛋白和球蛋白结合的毒物；活性炭HP可造成一过性血小板、红细胞不同程度的破坏。肝素用量应小于成人。

Objective In China, with the development of public health and medical treatment, accident became the first cause of death of children aged form 1 to 14 years, and poisoning became one of the main causes. The present study was conducted to investigate the efficacy of hemoperfusion （HP） on poisoning, and the pharmacokinetics of the poison during and after HP. The study was also to observe the effect of HP on blood cell and blood biochemistry, blood flow and dosage of heparin during HP in children. Methods Thirty-five children with acute poisoning （ including 26 boys and 9 girls aged from 10 months to 13 years, mean 3.35 ± 2. 50 years）were treated with HP for one to three times. Among them 12 children were treated with HP for two times and 4 children for three times. Two ml blood samples of 6 children with Fluoroacetamide （FAM） poisoning and 10 children with Tetramine （TET） poisoning were collected. The concentration of poison was measured by gas chromatography （GC）. Results The poisoning symptoms of all cases were relieved or alleviated obviously. In the end, 27 （77%） cases recovered and 6 （17%） cases improved, while 2 （6%） cases died of multi-organ failure （MOF）. Clinical symptom happened again 6-24 hours after HP in 1 case with FAM poisoning and 3 cases with TET whose clinical symptoms were relieved during HP. The PLT, RBC counts and Hb decreased significantly after HP compared with pre-HP （ P 〈 0. 05）, while WBC, alanine aminotransferase （ ALT）, aspartate aminotransferase （ AST）, reatine kinase （CK）, blood urea nitrogen （BUN）, creatinine （CRE）, Creatine kinase isoenzymes （CK-MB）, total protein （TP）, albumin （ALB） and globulim （GLO） after HP did not significantly change （P 〉0. 05）. The FAM concentration was significantly reduced （ P 〈 0. 030）. The concentration of TET in the poisoned children also significantly decreased with the treatment （P = 0. 001 ）. The cleaning efficacy of HP was higher during the first hour than that during the second hour of HP. The concentration of poison rose again 2-6 hours after HP in 1 case with FAM poisoning and 3 cases with TET poisoning, but the level was lower compared with pre-HP level. The t1/2 of FAM and TET with and without HP was （2. 40 ± 0. 66） h, （ 15.60 ± 8.22） h, （4. 10 ± 1.66）h and （67.01 ±48.42） h, respectively. The first dose of heparin was （0. 54 ±0. 15） mg/ kg; then （0. 20 ±0.06） mg/kg was added for every 30 minutes. The velocity of blood flow was （4. 39 ± 0. 99） ml/min. Conclusions The t1/2 of the poison was shortened, and the poison clering was accelerated by HP. The HP is a safe and effective therapy in children. The concentration of poison in some patient may rise again 2 to 6 hours after HP temporarily. The charcoal HP cannot remove the poison that conjugated with plasma albumin and globulin. The charcoal HP can cause temporary reduction of platelet and erythrocyte. The dosage of heparin used in children was lower than that in adult.