普鲁士蓝或联合血液灌流治疗急性铊中毒的疗效分析

Efficacy analysis of prussian blue or its combination with hemoperfusion in the treatment of acute thallium poisoning

目的探讨普鲁士蓝（PB）或联合血液灌流（HP）治疗急性铊中毒的疗效。方法选择2002年9月至2017年12月解放军第三〇七医院收治的资料完整的47例急性铊中毒患者，按中毒程度分为轻度中毒组（血铊〈150 μg/L、尿铊〈1000 μg/L）和中重度中毒组（血铊≥150 μg/L、尿铊≥1000 μg/L）。两组患者入院时均给予补钾、导泻、保护器官、营养神经、改善循环等对症支持治疗；同时，轻度中毒组口服PB 250 mg·kg-1·d-1，中重度中毒组在口服PB的同时给予HP治疗（每次持续2～4 h），根据患者血、尿铊监测结果调整PB剂量或HP应用频数。收集两组患者的性别、年龄、疼痛分级（数字分级法，NRS）、临床表现、治疗前后血铊和尿铊水平以及住院时间和预后。结果47例患者中，排除血、尿毒物检测数据不全及采用血浆置换、血液透析等治疗者，最终共29例患者纳入分析。① 29例患者中，男性20例，女性9例；中位年龄40.0（34.0，49.0）岁；临床表现均以神经系统、脱发为主，部分患者出现消化系统症状。轻度中毒组13例（占44.8%），疼痛分级为无痛（0级）或轻度疼痛（1～3级），临床症状较轻，住院时间为17.0（14.2，21.5）d；中重度中毒组16例（占55.2%），疼痛分级为中度疼痛（4～6级）或重度疼痛（7～10级），临床症状较重，住院时间为24.0（18.0，29.0）d。②治疗后轻度中毒组患者血铊和尿铊水平均较治疗前明显降低〔μg/L：血铊为0.80（0，8.83）比60.00（40.00，120.00），尿铊为11.30（0，70.10）比370.00（168.30，610.00），均P〈0.01〕；中重度中毒组血铊和尿铊水平也较治疗前明显降低〔μg/L：血铊为6.95（0，50.50）比614.50（245.00，922.00），尿铊为20.70（1.95，283.00）比5434.00（4077.20，10273.00），均P〈0.01〕。29例患者无一例死亡，且临床症状均得到明显改善。随访半年后，27例患者预后良好，无后遗症；2例重度急性铊中毒患者遗留神经系统损伤。结论针对急性铊中毒患者，在常规治疗基础上，轻度中毒者给予PB口服，中重度中毒者给予PB联合HP治疗均可获得满意疗效。

ObjectiveTo investigate the efficacy of prussian blue （PB） or its combination with hemoperfusion （HP） in the treatment of acute thallium poisoning.MethodsForty-seven patients with acute thallium poisoning with complete data hospitalized in the 307th Hospital of PLA from September 2002 to December 2017 were enrolled, and they were divided into mild poisoning group （blood thallium 〈 150 μg/L, urinary thallium 〈 1000 μg/L） and moderate-severe poisoning group （blood thallium ≥ 150 μg/L, urinary thallium ≥ 1000 μg/L） according to the toxic degrees. All patients were given symptomatic supportive treatments such as potassium supplementation, catharsis, vital organ protections, neurotrophic drugs, and circulation support. The mild poisoning patients were given PB with an oral dose of 250 mg·kg-1·d-1, while moderate-severe poisoning patients were given PB combined HP continued 2-4 hours each time. The PB dose or frequency of HP application was adjusted according to the monitoring results of blood and urine thallium. Data of gender, age, pain grading （numeric rating scale NRS）, clinical manifestations, blood and urine thallium before and after treatment, length of hospitalization and prognosis were collected.ResultsOf the 47 patients, patients with incomplete blood and urine test results, and used non-single HP treatment such as plasmapheresis and hemodialysis for treatment were excluded, and a total of 29 patients were enrolled in the analysis. ①Among 29 patients, there were 20 males and 9 females, median age of 40.0 （34.0, 49.0） years old; the main clinical manifestations were nervous system and alopecia, some patients had digestive system symptoms. There were 13 patients （44.8%） in the mild poisoning group with painless （grade 0） or mild pain （grade 1-3） with mild clinical symptoms, the length of hospitalization was 17.0 （14.2, 21.5） days. There were 16 patients （55.2%） in the moderate-severe poisoning group with moderate pain （grade 4-6） or severe pain （grade 7-10） with severe clinical symptoms, the length of hospitalization was 24.0 （18.0, 29.0） days. ② After treatment, the thallium concentrations in blood and urine in the mild poisoning group were significantly lower than those before treatment [μg/L： blood thallium was 0.80 （0, 8.83） vs. 60.00 （40.00, 120.00）, urine thallium was 11.30 （0, 70.10） vs. 370.00 （168.30, 610.00）, both P 〈 0.01], the thallium concentrations in blood and urine in the moderate-severe poisoning group were also significantly lower than those before treatment [μg/L： blood thallium was 6.95 （0, 50.50） vs. 614.50 （245.00, 922.00）, urinary thallium was 20.70 （1.95, 283.00） vs. 5434.00 （4077.20, 10273.00）, both P 〈 0.01]. None of the 29 patients died, and their clinical symptoms were improved significantly. All the 27 patients had good prognosis without sequela in half a year follow-up, and 2 patients with severe acute thallium poisoning suffered from nervous system injury.ConclusionIn the acute thallium poisoning patients, on the basis of general treatment, additional PB in mild poisoning group and PB combined with HP in moderate-severe poisoning group can obtain satisfactory curative effects.