六种有机磷农药急性中毒早期并发症的对比研究

Comparative study of the incidence of early complications among the patients with six different kinds of acute organophosphorus pesticide poisoning

目的探讨不同种类急性有机磷农药中毒72h内并发症的发生率，为制定相应的临床救治方案提供参考。方法回顾性分析2008年7月至2015年12月解放军第307医院急诊科收治的335例急性口服有机磷农药中毒患者的病例资料。按照血液毒物检测的结果分成6组：即急性甲拌磷中毒组（A组）、急性敌敌畏中毒组（B组）、急性氧乐果中毒组（C组）、急性乐果中毒组（D组）、急性辛硫磷中毒组（E组）及急性对硫磷中毒组（F组）。比较各组患者中毒24h内呼吸心搏骤停，72h内的病死率和急性呼吸衰竭、急性循环衰竭、脑水肿、多脏器功能障碍综合征（NODS）、肾脏损伤、肝脏损伤、心肌损伤、凝血异常、消化道出血、急性胰腺炎及毛细血管渗漏综合征（CLS）的发生率，组间比较采用秩和检验。结果各组患者在脑水肿、肝损伤、肾损伤、心肌损伤、消化道出血及急性胰腺炎的发生率差异无统计学意义（P〉0．05）；而在病死率和呼吸心搏骤停、急性呼吸衰竭、急性循环衰竭、MODS、凝血异常、CLS的发生率比较，差异有统计学意义（P〈0．05）。其中，服毒后24h内急性敌敌畏中毒组发生呼吸心搏骤停的发生率高达17．8％，而其他各组发生率依次为：对硫磷组11．1％、乐果组8．9％、甲拌磷组7．8％、氧乐果组1．5％，辛硫磷组0％。服毒后72h内死亡的病例仅见于敌敌畏组，共3例；急性循环衰竭的总发生率为10．1％，多见于敌敌畏组（31．1％）和乐果组（22．2％），其他组发生率较低；急性呼吸衰竭的总发生率高达36．7％，各组发生率均在20％以上，发生率超过40％的有甲拌磷组（46．7％）、敌敌畏组（44．4％），对硫磷组（44．4％）和乐果组（42．2％）；凝血异常的发生率为9．6％，发生率超过10％的有敌敌畏组（24．4％）、甲拌磷组（11．6％）和对硫磷组（11．1％）；CLS仅见于敌敌畏组和甲拌磷组，发生率分别为11．1％和2．5％；MODS主要见于敌敌畏组和对硫磷组，发生率分别为28．9％和22．2％。结论6种急性有机磷农药中毒患者早期并发症发生率差异显著，急性口服敌敌畏中毒者在24h内更易发生呼吸心搏骤停。而中毒72h内急性甲拌磷中毒组更易发生急性呼吸衰竭，急性敌敌畏中毒组则易发生凝血异常、急性循环衰竭、毛细血管渗漏综合征及多脏器功能衰竭。急性氧化乐果中毒组和急性辛硫磷中毒组患者发生各类并发症机率最小。

Objective To explore the incidence of early complications within 72 hours among patients with six kinds of acute organophosphorus pesticide poisoning, thus to provide reference for the clinical treatment. Methods The retrospective study analyzed the clinical data of 335 cases with acute oral organophosphorus pesticide poisoning treated in Emergency Department of 307 Hospital of PLA from July 2008 to December 2015. Patients were divided into six groups according to the results of serum toxicology tests： acute phorate group （group A）, acute dichlorvos group （group B）, acute omethoate group （group C）, acute dimethoate group （group D）, acute phoxim group （group E） and acute parathion group （group F）. The incidence of complications among the six groups were compared. The main analysis method was ranks test. Results There were no significant differences among the six groups in the incidence of cerebral edema, liver injury, kidney injury, myocardial injury, gastrointestinal hemorrhage and acute pancreatitis （P 〉 0. 05 ）, while the mortality and the incidence of sudden cardiac arrest （SCA）, respiratory failure, circulatory failure, multiple organ dysfunction syndrome （MODS）, coagulation disorders and capillary leak syndrome （CLS） were significantly different among the six groups （P 〈0. 05 ）. The incidence of SCA wihin 24 hours in acutedichlorvos group reached up to 17.8% , and in other groups was as follows： acute parathion group （11.1%）, acute dimethoate group （8.9%）, acute phorate group （7.8%） and acute omethoategroup （ 1.5% ）. However, no one developed SCA in acute phoxim group. The total incidence of circulatory failure in all patients was 10. 1% ; dichlorvos group 31.1% and dimethoate group （22. 2% ） had higher rates than other groups. The incidence of respiratory failure in all groups reached over 20% , while the total incidence was 36. 7%, whereby, acute phorate group with a high of 46. 7%, acute dichlorvos group with 44.4% , acute parathion group with 44. 4% and acute dimethoate group with 42. 2% , respectively. The total incidence of coagulation disorders was 9.6%, while the incidences of the acute dichlorvos group （24.4%）, acute phorate group （ 11.6% ） and acute parathion group （ 11.1% ） were higher than 10%. CLS confined to occur in acute dichlorvos group （ 11.1% ） and acute phorate group （2. 5% ）. However, MODS occurred mainly in acute dichlorvos group （28.9%） and acute parathion group （22. 2% ）. Conclusions The incidences of early complications among the six groups are different, while acute oral dichlorvos poisoning patients tend to occur SCA. Within 72 h of poisoning, acute phorate poisoning group is more prone to respiratory failure, and acute dichlorvos poisoning group is more likely to develop coagulopathy disorders, circulation failure, CLS and MODS. Those patients in acute omethoate and acute phoxim poisoning groups have less risk to develop life-threatening complications except respiratory failure.