单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,坚守的理由,百草枯,中毒预后,评价,Prediction of Outcome in Patients with Paraquat,Poisioning,坚守的理由百草枯中毒预后评价,2016,年以后的百草枯中毒,2016,年,7,月,1,日停止水剂在国内销售和使用,。,2016年以后的百草枯中毒2016年7月1日停止水剂在国内销,韩国,2012,年禁用百草枯,Bang,YJ,Kim J,Lee WJ:,Paraquat use among farmers in Korea after the ban,.,Arch Environ Occup Health,2016:0.,Cha,ES,Chang SS,Gunnell D,Eddleston M,Khang YH,Lee WJ:,Impact of paraquat regulation on suicide in South Korea,.,Int J Epidemiol,2016,45,(2):470-479.,杀虫脒、氟乙酰胺、毒鼠强、甲胺磷、对硫磷、甲基,对,硫磷,病例数量：,农药中毒第,二,位,死亡绝对数：,农药中毒,第,一,位,死亡绝对数第一,韩国2012年禁用百草枯Bang YJ,Kim J,Le,从未救活过,50%,死亡率,治愈率,67%,？,共识,?&,非共识,?,2013,专家共识,脓毒症的启示,单击添加段落文字,1.,卢,中秋,.,百草枯急性中毒救治中的几个焦点问题,.,中华劳动卫生职业病杂志,.,2013;31,(5,):395-397.,2.,中国医师协会急诊医师,分会,.,急性百草枯中毒诊治专家共识,(2013).,中国急救医学,.,2013;33,(6):484-490,.,从未救活过共识?&非共识?2013专家共识脓毒症的启示单击添,治疗的基石,1,一点儿理由,3,预后探索,当前介绍,内容,2,目 录,Contents,Page,5,治疗的基石1一点儿理由3预后探索当前介绍内容2目 录 Con,6,治疗的基石,1,免疫抑制,血液净化,6治疗的基石1免疫抑制血液净化,百草枯中毒机制,分子机制,组织变化,PQ,氧化还原循环,肺泡上皮细胞死亡,单核巨噬细胞活化,炎症反应,百草枯中毒机制分子机制组织变化PQ氧化还原循环肺泡上皮细胞死,N=111,治疗组：,59,例，对照组：,52,例,2002,2011,Lin JL,Lin-Tan DT,Chen KH et al.Improved survival in severe paraquat poisoning with repeated pulse therapy of cyclophosphamide and steroids.Intensive Care Med.2011;37:1006-13.,CP(2,mg/kg,per,day),DEX,(5 mg every 6 h),for 14 days.,CP1,g/day,两,天,甲强龙,1g/day,三天,DEX5mg,qid,甲强龙,1g/day,三天,必要,CP 1,g/day,1,天,冲击治疗续贯激素，必要时再冲击治疗,较大样本,N=111 治疗组：59例，对照组：52例2,早期血液灌流治疗过程中，你选择,1,次,3,小时灌流，还是,2,次,X3,小时灌流，,3,次,X3,小时,灌流，,4,次,X3,小时,灌流,?,如果,15,小时灌流，可以把血中百草枯浓度降到可检测浓度以下，你会选择连续灌流，还是,D1,3,次,+D2,2,次？,血液净化治疗是保障,早期血液灌流治疗过程中，你选择1次3小时灌流，还是2次X3,早期血液净化联合免疫抑制治疗,早期血液净化联合免疫抑制治疗,11,预后探索,2,11预后探索2,面对百草枯中毒患者，我们如何判断预后？,12,服毒量,百草枯浓度,尿百草枯浓度,中毒严重指数,APACHEII,SOFA,白细胞数,尿酸,胆红素,PH,动脉,LAC,PaCO2,HCO3,面对百草枯中毒患者，我们如何判断预后？12服毒量百草枯浓度尿,中青年病人？灰区病人？,13,中青年病人？灰区病人？13,大剂量激素、血液净化治疗,14,大剂量激素、血液净化治疗14,15,预后评估,-,百草枯浓度,分组,存活组（,n=98,）,死亡组（,n=91,）,P,年龄,（,Y,）,29.30,12.68,33.2313.50,0.236,中毒时间（,h,）,5.00(4.00,8.00),7.00(4.13,9.75),0.008,百草枯浓度,(mg/L),4.70(2.80,6.40,),9.90(6.20,14.70),0.000,PQ,中毒时间乘积,(mg/L.h),25.20(12.80,44.80,),73.50(45.60,124.80),0.000,pH,7.41(7.39,7.43,),7.40(7.36,7.43),0.078,PaO,2,(mmHg),88.00(80.00,102.00,),93.00(8100,109.00),0.050,PaCO,2,(mmHg),36.50(31.00,39.00,),33.00(25.50,39.00),0.002,AST(IU/L),30.00(22.00,37.00,),36.00(22.75,61.00),0.020,ALT(IU/L),19.00(14.00,27.00,),21.00(13.00,37.00),0.440,TBIL(mg/dL),52.00(44.00,62.00,),62.00(48.00,83.00),0.005,BUN(mg/dL),4.80(3.70,5.85,),5.10(3.90,6.95),0.014,Creatinine,(mg/dL),52.00(45.00,62.25,),61.00(47.25,82.50),0.005,表,1,189,例百草枯中毒患者的一般状况及生化指标,15预后评估-百草枯浓度分组 存活组（n=98）死,图：中毒后,6h,内，,百草枯浓度及百草枯浓度,与中毒时间乘积的,ROC,曲线，根据两条曲线的对比分析可见，两条曲线,下的面积差异显著,（,z=2.199,P,=0.034,）,16,表,2,中毒小于等于,6h,患者的年龄、中毒时间、百草枯浓度及初始生化数据的,logistic,回归分析,回归系数,OR,值,95%CI,P,PPQ,-0.349,0.679,0.782,0.904,0.000,预后评估,-,百草枯浓度,根据,ROC,曲线分析,，中毒时间在,6h,以内时，百草枯浓度的阈值为,6.4mg/L,16表2 中毒小于等于6h患者的年龄、中毒时间、百草枯浓度及,图,6,：中毒大于,6h,百草枯浓度及百草枯浓度,与中毒时间乘积的,ROC,曲线，根据两条曲线的对比分析可见，两条曲线下的面积差异显著,（,z=2.525,P=0.012,）,。,17,表,3.,中毒时间在,6,至,48h,的,百,草枯浓度,、浓度与时间的乘积及中毒时间的,ROC,曲线分析（,N=83,）,表,4,中毒时间在,6-48h,患者的年龄、中毒时间、百草枯浓度及初始生化数据的,logistic,回归分析,预后评估,-,百草枯浓度,回归系数,OR,值,95%CI,P,入院时,PQ,浓度,-0.405,0.667,0.782,0.904,0.000,中毒时间,-0.108,0.898,0.827,0.974,0.009,年龄,-0.067,0.935,0.883,0.989,0.021,阈值,敏感性,%,特异性,%,AUC(95%CI),最佳约登指数,初始,PQ,浓度,(mg/L),9.2,96.87(83.80,99.90,),43.14,(29.30,，,57.8,),0.708,(,0.598,0.802),0.400,PQ,时间乘积,(mg/L.h),73.6,87.50(,71.00,96.50,),68.63,(,54.10,80.90),0.821,(,0.722,0.897),0.561,中毒时间（,h,）,17,93.75,(,79.20,99.20),25.49,(14.30,39.60,),0.576,(,0.463,0.684),0.192,17表 3.中毒时间在6至48h的百草枯浓度、浓度与时间的,血浆百草枯的定量分析可评估病情的严重程度和预后，目前国内尚无统一的检测标准。,18,放射免疫法,固相提取、硫代硫酸钠浓缩、分光光度测定法,液相色谱,-,质谱联用,.,血浆百草枯的定量分析可评估病情的严重程度和预后，目前国内尚无,预后评估,-,乳酸,表,5,.170,例百草枯中毒患者一般状况,表,6,百草枯中毒后相同时间点动脉乳酸和百草枯浓度相关性分析,参数,统计参数,初始,PQ,浓度,PQ,浓度时间积,初始动脉乳酸,相关系数（）,0.414,（,N=170,）,P,值,0.001,动脉乳酸时间积,相关系数（）,0.485,（,N=170,）,P,值,0.001,存活组（,n=93,）,死亡组（,n=77,）,P,年龄,(years),30.00(23.00,45.5,0,),29.00(24.00,46.50),0.518,服毒时间,(h),5.00,(4.00,8.00),6.00,(4.00,8.75),0.117,初始动脉乳酸,(mmol/L),2.00,(1.00,2.50),5.00,(2.00,10.00),0.000,动脉乳酸时间乘积,(mmol/L.h),10.00(5.00,17.50),26.10(15.00,53.55),0.000,初始,PQ,浓度,(mg/L),5.00(3.00,7.00),10.0,(6.00,15.00),0.000,PQ,浓度时间积,(mg/L.h),26.50(13.50,47.50),59.00(35.50,104.50),0.000,预后评估-乳酸表5.170例百草枯中毒患者一般状况表6 百草,20,阈值,敏感性,%,特异性,%,AUC(95%CI),最佳约登指数,初始动脉乳酸,(mmol/L),4.20,82.80(73.57,89.83),63.64(51.89,74.30),0.774(0.703,0.834),0.464,动脉乳酸时间积,(mmol/L.h),11.95,64.52(53.91,74.17),84.42(74.36,91.68),0.782(0.712,0.841),0.490,初始,PQ,浓度,(mmol/L),9.35,86.02(77.28,92.34),59.74(47.94,70.77),0.765(0.694,0.826),0.462,PQ,浓度时间积,(mg/L.h),22.70,44.01(32.79,53.69),92.21(83.81,97.09),0.768(0.697,0.829),0.362,中毒时间（,h,）,6.50,66.67(56.31,75.96),48.05(36.52,59.74),0.568(0.490,0.644),0.145,表,7,乳酸,、,乳酸时间积,、,百草枯浓度,、百草枯时间积和中毒时间的,ROC,曲线分析,表,8,百草枯中毒后初始参数的多因素,logistic,回归分析,参数,回归系数,OR,95%CI,P,中毒时间,-0.149,0.869,0.774,，,0.978,0.002,初始动脉乳酸,-0.151,0.838,0.755,，,0.930,0.001,初始,PQ,浓度,-0.182,0.856,0.794,，,0.923,0.001,预后评估,-,乳酸,20阈值敏感性%特异性%AUC(95%CI)最佳约登,21,刘晓伟。动脉血乳酸对急性百草枯中毒患者预后的预测价值,.,中华急诊医学杂志，,2013,12,(,11,),1219-1222,阈值,敏感性,%,特异性,%,AUC(95%CI),最佳