大量砒霜攝取導致之急性腎衰竭及死亡 Acute Renal Failure and Mortality Following...
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大量砒霜攝取導致之急性腎衰竭及死亡大量砒霜攝取導致之急性腎衰竭及死亡Acute Renal Failure and Mortality Acute Renal Failure and Mortality Following Massive Arsenic Trioxide Following Massive Arsenic Trioxide IngestionIngestion
侯羿州 , 林杰樑 , 顏宗海 Yi-Chou Hou, Ja-Liang Lin, Tzung-Hai Yen林口長庚紀念醫院 腎臟系 臨床毒物科Chang Gung Memorial Hospital, Linkou department, Taoyun, Taiwan
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Patient InformationPatient Information
Age: 57-year-oldGender: maleOccupation: Teacher (chemistry)Marital status: married
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ChiefChief ComplaintComplaintIngestion of 30 grams of asrsenics
trioxides ( 砒霜 ).
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Present IllnessPresent Illness 14:00 on 12/30- his colleagues
found him taking 30 grams of arsenic trioxide ( 砒霜 ).
Excessive salivation and epigastralgia with persistent vomiting.
Shortness of breath and abdominal pain occurred concurrently.
15:30-he was referred to our ER.
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Physical ExaminationPhysical ExaminationT:37℃ P:80 beats/min R:16times /min BP:116/81mmHg Consciousness: Clear, E 4 V 5 M 6 HEENT: Sclera: not icteric; Conjunctiva: not pale Oral cavity : intact oral mucosa Chest: Symmetric expansion. Bilateral clear breathing sounds.Heart: regular heart beat without murmur.Abdomen: Soft and flat. No tenderness. No hepatosplenomegaly. Extremities: No pitting pitting edema.
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Laboratory (16:13)Laboratory (16:13)
WBC(/uL) 11800 BUN(mg/dL) N/A
Hb(g/dL) 15.3 Cr(mg/dL) 1.4
MCV(fL) 87.5 Na(meq/L) 137
RDW(%) 13.5 T. Bil(mg/dL) 1.0
Platelet(uL) 179000 K(meq/L) 3.7
Seg(%) 91.4 ALT(U/L) 103
PT INR N/AUric
acid(mg/dL)5.7
aPTT N/A Sugar( mg/dL) 144
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Sinus Tachycardia
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15:30-Arrived at CGMH ERDecontamination, Gastric lavage, IVF supportCheck Arsenic level
17:00-Contacted with 台北榮總解毒劑中心 for antidote.
21:00-Respiratory distress, hypoxic respiratory failure and shock occurred.
Fluid resuscitation(1000ml) and high dose norepinephrine were prescribed for shock.
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Arterial blood gasArterial blood gas beforebefore intubationintubation(21:00)(21:00)
pH: 7.331PaO2 82.9mmHg (FiO2: 100%)PCO2: 23.5mmHgHCO3: 12.1mmol/LSBE:-13.8mmol/L
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ManagementManagement
22:20-endotracheal intubation with mechanical ventilator support.Transfer to ICU.Continue fluid resuscitation with high dose inotropic agents for shock status1st 2,3- dimercaptol propanesulfonic acid (DMPS) 250mg IVF at 23:30(9hrs).
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Laboratory data at ICULaboratory data at ICU
WBC(/uL) 49600
Hb(g/dL) 15.4 Cr(mg/dL) 3.68
Platelet 166000 Na(meq/L) 145
Band(%) 12.1 Ca(mg/dL) 7.4
Lympho(%) 10.0 K(mEq/L) 2.8
Seg(%) 73 ALT(U/L) 98
PT INR N/ATroponin I(ng/mL)
20.958
aPTT N/ALactate(mg/
dL)99.05
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12/31 2:0012/31 2:00 (12(12 hrshrs afterafter ingestion)ingestion)
Arrange CVVHD for metabolic acidosis and shock.
Asystole before CVVHD was set. CPCR but failure.
Critical AAD.
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Arsenic serum levelArsenic serum level (1.5(1.5 hrhr afterafter exposure)exposure)
730ug/L (normal range: <20ug/L)
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DiscussionDiscussion Arsenics is one of the most
toxic metals derived from the natural environment.
Most common form: 5+, 3+, 3- Organic : with hydrogen and
oxygenInorganic: with Sulfur, chloride or oxygen
Inorganic arsenics is toxic. Postgrad Med J 2003
79: 391-396
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ArsenicsArsenics As2O3: most common form in
environment, especially in water, soil or seafood, color pigments.
Murder weapons with sugar used by ancient Chinese.
Treatment of acute myelogenous leukemia -M3: (relapse status after ATRA).
Cosmetic products, <5ppm.
Postgrad Med J 2003 79 391-396
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PharmacokineticsPharmacokinetics
Absorbed rapidly from GI tract with 100% bioavailability.
Rapid redistribution from blood (half life 1 hr.)
Inorganic arsenic can be either methylated to form monomethylarsonic acid or dimethylated as in dimethylarsinic acid.
K.Jonova: Journal of Applied.
Toxicology. 2011; 31: 95–107
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The methylation of inorganic arsenic has been considered to be a detoxification mechanism
Clearance from bloodPhase 1: from serum to tissue (90%, 30 mins)Phase 2: to tissue (RBC, 10%)Phase 3: from tissues and RBC into plasma then renal elimination.
K.Jonova: Journal of Applied.
Toxicology. 2011; 31: 95–107
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PEDIATRICS Vol. 116 No. 1 July 2005
Pyruvate+thiamine pyrophosphate(TPP)-> hydroethylTPP+lipoamide->aceyl-CoA+dihydrolipoamide
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PEDIATRICS Vol. 116 No. 1 July 2005
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Acute poisoningAcute poisoning ofof ArsenicsArsenics
Lethal dose: 100-500mg <24hrs :
Hematemesis and diarrhea within 1 to 4 hs after ingestion.
Garlic odor. Gastrointestinal volume loss due to
capillary permeability change. QTc prolongation, arrhythmia,
cerebral edema, microhemorrhage Acute tubular necrosis or
hemogloburinuria due to hemolysis may occur.
PEDIATRICS Vol. 116 No. 1 July 2005
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ManagementManagement Decontamination:
Skin decontaminationGI decontamination: gastric lavage and active charcoal.
Fluid resuscitation to maintain urine flow.
Chelating agents: DMPS, BAL
MUNDY SW: GOLDFRANK’S TOXICOLOCIAL EMERGENCIES,
2010
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Dimercaprol ( BAL in oil)Every 50 mg BAL binds to 30 mg
arsenics.Administrate as intramuscular
injection.Bioavailability is unpredictable in
patients with shock. The only chelating agent to cross
blood-brain barrier.
Journal of Anal Toxicol. 1989; 13:310 –312
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2,3,2,3, d dimercaptolimercaptol propanesulfonicpropanesulfonic acid acid (DMPS)(DMPS)
Water analog to BAL. Chelating to metabolite of
arsenics, especially first methylated arsenics.
Increase urine excretion (>3 folds) within 2 hours if given as early as possible.
J Pharmacol Exp Ther.
1997;282:192–200
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Extracorporeal EliminationExtracorporeal Elimination HD ineffective: low dialysate
arsenic concentration in several studies suggested rapid distribution to tissue.
DMPS-As is not dialyzable. HD when uremia symptoms
develop. CVVHDF may be considered for
convective mass transport.(?)PEDIATRICS Vol. 116 No. 1 July 2005