RU2413944C1 - Method of evaluating severity of acute opioid poisoning - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: evaluation of severity of opioid poisoning is carried out by determining degree of depression of consciousness, degree of reflex activity depression and presence or absence of complications in respiratory system. Additionally determined is gas and acid-gas contents of arterial blood with further building of oxyhemoglobin dissociation curve for determination of semi-saturation blood pressure and 2,3-diphosphoglycerate. Further, on the basis of said indices opioid poisoning is evaluated as of mild, medium and severe degree of poisoning. ^ EFFECT: increase of efficiency of diagnosing severity of acute opioid poisoning. ^ 3 dwg, 3 ex

Description

The invention relates to medicine, namely to toxicology, and can be used in clinical laboratory diagnostics of patients with opioid poisoning.

Acute poisoning with psychotropic drugs (drugs of the opium group, noxiron, tranquilizers and antipsychotics) currently occupy a leading place among household intoxications of chemical etiology, and their frequency continues to increase. Therefore, in case of poisoning with psychotropic drugs, the differential diagnosis of coma, when patients enter a hospital unconscious, often with respiratory and hemodynamic impairments, is of the greatest practical importance. The reduction in mortality in this pathology depends on the timely diagnosis of coma.

The most famous methods for the diagnosis of narcotic poisoning are tests based on color reactions of chemical solutions with the studied objects. One of the most common methods of analysis is thin-layer chromatography (Shvaikova MD Toxicological chemistry. M: Medicine, 1975. - 144 p.).

However, this technique does not allow to assess the severity of poisoning.

There is also a method for diagnosing the severity of poisoning with narcotic and / or potent substances by determining the acidity (pH) of blood serum, as well as studying serum by the method of wedge-shaped dehydration, subsequent analysis of the structure of the obtained dehydrated drop in a light microscope (patent RU No. 2332666, IPC G01N 33/49 G01N 33/84, published April 16, 2007).

This method does not allow to identify the severity of poisoning.

In our country, to assess the severity of poisoning by opiates, the most frequently used classification is Sukhinin-Luzhnikov (Luzhnikov E.A. Acute poisonings. - M .: Medicine, 1982.-260 s). The closest is the clinical and neurological method for the diagnosis of acute poisoning with psychotropic drugs, which allows detecting up to 4 stages of poisoning: 1st (stage of falling asleep = light poisoning), 2nd (superficial coma = moderate poisoning), 3rd ( deep coma = severe poisoning) and 4th (stage of awakening). This classification is based on three main points: the degree of depression of consciousness, the degree of depression of reflex activity and the presence or absence of complications, primarily from the respiratory system (Clinical and neurological method for the diagnosis of acute poisoning with psychotropic drugs. Methodical recommendations. M: Ministry of Health of the RSFSR, 1980 .-- 18 p.).

This method allows you to timely diagnose coma caused by drug poisoning with psychotropic effects, but the effectiveness of this method is not sufficient.

The objective of the invention is to improve the method for assessing the severity of patients with opioid poisoning.

The technical result that will be achieved from the use of this invention is to increase the efficiency of the diagnosis of the severity of acute poisoning with opioids.

The technical result is achieved by the fact that in the method for assessing the severity of acute poisoning with opioids, including the degree of depression of consciousness, the degree of depression of reflex activity and the presence or absence of complications from the respiratory system, the gas and acid-base composition of arterial blood is additionally determined with the subsequent construction of an oxyhemoglobin dissociation curve to determine hemosaturation blood pressure and 2, 3-diphosphoglycerate.

With blood acidity (pH) 7.2 ± 0.05, oxygen tension in arterial blood (PaO ₂ ) 57.5 ± 1.1, carbon dioxide voltage in arterial blood (PaCO ₂ ) 58.7 ± 1.4 mm RT Art., the concentration of carbonic acid anions in the blood (HCO ₃ ) 25.4 ± 0.2 meq / l, hemisphere pressure of the blood (P ₅₀ ) 28.7 ± 0.5 mm Hg and a content of 2, 3-diphosphoglycerate (2,3-DPH) 4.8 ± 0.3 mmol / L, a mild degree of acute poisoning is diagnosed.

With a blood acidity of 7.35 + 0.01, an oxygen tension in arterial blood of 55.1 + 1.0, a carbon dioxide voltage in arterial blood of 64.1 ± 0.9 mm Hg, a concentration of carbonic acid anions in the blood 35 , 4 ± 0.6 meq / l, hemisphere pressure of blood 33.9 ± 0.5 mm Hg and a content of 2,3-diphosphoglycerate of 7.4 ± 0.5 mmol / L, a moderate degree of acute poisoning is diagnosed.

With a blood acidity of 7.11 ± 0.1, an oxygen tension in arterial blood of 45.1 ± 1.1, a carbon dioxide voltage in arterial blood of 70.1 ± 1.6 mm Hg, a concentration of carbonic acid anions in the blood 21 , 6 ± 0.2 meq / l, hemisphere pressure of blood 33.0 ± 0.7 mm Hg and the content of 2,3-diphosphoglycerate 6.4 ± 0.3 mmol / l diagnose a severe degree of acute poisoning.

The essence of the invention is to create an objective classification for assessing the severity of patients with acute opioid poisoning.

The additional information obtained allows one to determine the ventilation function of the lungs, objectively determines violations of the gas composition of the blood, and the construction of an oxyhemoglobin dissociation curve - to assess its ability to give oxygen to tissues.

Determination of gas and acid-base blood composition and classification of these indicators obtained as a result of studies on the three severity levels of poisoning.

- For easy:

pH (blood acidity) - 7.2 ± 0.05

PaO ₂ (oxygen tension in arterial blood) - 57.5 ± 1.1 mm Hg;

PaCO ₂ (carbon dioxide tension in arterial blood) - 58.7 ± 1.4 mm Hg;

НСО ₃ (concentration of carbonic anions) - 25.4 ± 0.2 meq / l;

P ₅₀ (semi-saturation pressure) - 28.7 ± 0.5 mm Hg;

2,3-DPH (2,3-diphosphoglycerate) - 4.8 ± 0.3 mmol / L.

- For medium:

pH 7.35 ± 0.01

RAO ₂ - 55.1 ± 1.0 mm Hg;

PaCO ₂ - 64.1 ± 0.9 mm Hg;

NSO ₃ - 35.4 ± 0.6 meq / l;

P ₅₀ - 33.9 ± 0.5 mm Hg;

2,3-DFG - 7.4 ± 0.5_mmol / l.

- For heavy:

pH - 7.11 ± 0.1

RAO ₂ - 45.1 mm Hg;

PaCO ₂ - 70.1 ± 1.6 mm Hg;

NSO ₃ 21.6 ± 0.2 meq / l;

P ₅₀ - 33.0 ± 0.7 mm Hg;

2,3-DFG - 6.4 ± 0.3 mmol / L.

they allow one to reliably evaluate in a patient in a coma the severity of the pathological process and its dynamics during intensive care.

From an analysis of the scientific, technical and patent literature of the claimed combination of features and the establishment of a quantitative criterion - the gas and acid-base composition of the blood, we have not identified, which allows us to conclude that the proposed solutions meet the criteria of "novelty" and "inventive step".

The invention is as follows.

Upon the patient’s admission to the poison control center during the examination of the patient by a doctor, they determine the degree of depression of consciousness by checking the possibility of the patient coming into contact with the doctor, the adequacy of answers to the questions posed, the patient’s orientation in place, time, and self. Reflex activity is determined by standard methods used in examining a neurological patient (tendon reflexes with a neurological hammer in the popliteal areas, on the forearms; Babinsky - from the foot, eye reflexes - determining the size of the pupil and its reaction to light). Identify the presence or absence of complications from the respiratory system. Then an analysis of the acid-base and gas composition of arterial blood is carried out.

Assessment of the acid-base state (CBS) was carried out by an express method for determining blood pH, carbon dioxide tension of PaCO ₂ , concentration of carbonic acid anions HCO ₃ (Astrup, Schroder; Siggaard-Andersen et al., Astrup et al.).

In their study, the authors used the “Blood Gas Analyzer, Acid-Base Equilibrium (COR) and RapidLab 348 Electrolytes” from Bayer, Germany, which, as its name suggests, makes it possible to obtain a full range of blood gas composition, CDF and electrolytes.

After placing a blood sample in the analyzer, all stages of the study are carried out automatically without the participation of a laboratory assistant.

The calculations are carried out taking into account the following standard conditions:

1. Barometric pressure - 760 mm Hg

2. The oxygen content in the gas mixture is 21%.

3. The hemoglobin content is 130 g / l.

4. The saturation of hemoglobin with oxygen is 95%.

5. The normal pH level of arterial blood is 7.36-7.42.

6. The normal level of PaO ₂ is 60-100 mm Hg.

7. The normal level of PaCO ₂ arterial blood is 36-40 mm Hg.

Subsequently, the Oxygen Status Algorithm (OSA) computer program was used to calculate the determination of pH and blood gas parameters developed by the Danish scientist Siggaard-Andersen and co-authors (Siggaard-Andersen, Ole & Siggaard-Andersen, Mads. The oxygen status algorithm: a computer program for calculating and displaying pH and blood gas data. Scand J Clin Lab Invest, 1990; 50, Suppl. 203: 29-45. O. Siggaard-Andersen, IH Gothgen, PD Wimberley & N. Fogh- Andersen. The oxygen status of the arterial blood revised; relevant oxygen parameters for monitoring the arterial oxygen availability. Scand J Clin Lab Invest 1990; 50, Suppl. 203; 17-28.), which allowed us to obtain the calculated parameters of two most important indicators characterizing the position of the dissociation curve ation oxyhemoglobin - R ₅₀ and - 2,3-DPG.

Examples of specific embodiments of the invention.

Example 1. Patient M, 24 years old, was admitted to the poison control center on 12/02/07. According to relatives, the exposure has been about 1.5 hours since the injection of heroin. The antidote Naloxone was not administered at the prehospital stage. Consciousness is oppressed, but it is trying to indistinctly answer the questions posed. The skin is pale, moderate cyanosis of the lips, the pupils are evenly narrowed, with a sluggish reaction to light. The corneal reflex is saved. Tendon reflexes are reduced. The respiratory rate in 1 minute is 15. Heart sounds are deaf, heart rate (heart rate) is 78 in 1 minute. HELL - 110/60 mm Hg The concentration of poison in the urine is 6.3 μg / ml. In the study of the gas composition of the blood, a decrease in the stress of PaO ₂ to 58.1 mm Hg was noted, decompensated respiratory acidosis was recorded in the patient's blood (pH 7.2, PaCO ₂ 59.3 mm Hg, NSO ₃ 25 , 3 meq / l). The oxyhemoglobin dissociation curve was constructed: P ₅₀ - 28.7 mm Hg, level 2,3-DPH - 4.8 mmol / L. In fact, despite changes in the pH of arterial blood and PaCO _{2, the} shift of the oxyhemoglobin dissociation curve down and to the right was not registered by us. In accordance with the classification of Sukhinin-Luzhnikov (1966), the severity of the condition corresponds to a mild degree of acute poisoning with psychotropic drugs - the stage of falling asleep. The level of morphine in the patient's urine corresponds to a mild stage. After intravenous administration of Naloxone at a dose of 1.2 mg, the patient's condition improved. The patient is conscious, oriented in place and time. Respiratory rate increased to 18 in 1 minute. After 30 minutes, when studying the gas composition of the blood - RaO ₂ , the pH of the arterial blood returned to normal, the pH was 7.38 mm Hg. The level of PaCO ₂ decreased to 42 mm Hg. Against the background of infusion therapy, repeated administration of Naloxone was not required. After 5 hours, the patient was removed from the intensive care unit in satisfactory condition.

Example 2. Patient Z., 25 years old, was admitted to the poison control center on January 15, 2006. The exposure of the poison was 7.5 hours. Naloxone was not administered at the prehospital stage. Upon receipt, the contact is not available. The pupils are narrowed, without reaction to light. The corneal reflex is inhibited. Tendon reflexes are sharply reduced. Respiratory rate - 9 in 1 minute. Severe acrocyanosis, cyanosis of the neck, auricles. Heart sounds are deaf. Pulse - 108 in 1 min.

The concentration of poison in the urine is 10.3 μg / ml. In the study of the gas composition of the blood, a decrease in RaO _{2 of} arterial blood to 55.1 mm Hg was noted. In arterial blood, compensated respiratory acidosis was noted (pH -7.35, PaCO ₂ - 65.0, NSO ₃ - 35.3 meq / l). An oxyhemoglobin dissociation curve was constructed: P ₅₀ - 33.4 mm Hg, level 2,3-DPH - 6.9 mmol / L. The hemoglobin dissociation curve shifted to the right and down, which ensured tissue oxygenation. In accordance with the classification of Sukhinin-Luzhnikov (1966), the severity of the condition corresponds to the middle stage of acute poisoning with psychotropic drugs - the stage of superficial coma 2B. The level of morphine in the patient's urine corresponds to the middle stage. After administration of Naloxone at a dose of 1.6 mg intravenously, the patient's condition improved, the patient was conscious, the respiratory rate was 20 in 1 minute, blood pressure was 130/70 mm Hg, tachycardia was 112 in 1 minute. After 30 minutes, when studying the gas composition of the blood, RaO ₂ increased and amounted to 77.4 mm Hg, the pH of arterial blood approached the norm, amounting to 7.34. The level of PaCO ₂ decreased to 41.1 mm Hg. The oxyhemoglobin dissociation curve shifted up and to the left. The patient's condition progressively improved. Violations of mental activity and respiratory function were not observed. After 12 hours, the patient is in satisfactory condition removed from the intensive care unit.

Example 3. Patient M., 22 years old, was admitted to the poison control center on 08.06.2005. The time of drug administration is unknown. Naloxone was not administered at the prehospital stage. Upon admission, the patient is in serious condition. During transportation, mechanical ventilation was performed using the AMBU mask. On examination, consciousness is absent. The pupils are narrowed, without reaction to light. The corneal reflex is absent. Tendon reflexes are not caused. Respiratory rate - 7 in 1 minute. Severe cyanosis of the face, cyanosis of the neck, auricles, acrocyanosis. Heart sounds are deaf. Pulse - 120 in 1 min. The concentration of poison in the urine is 12.1 μg / ml.

In the study of the gas composition of the blood, a decrease in RaO _{2 of} arterial blood to 45.1 mm Hg was noted. In arterial blood, a combination of respiratory acidosis with metabolic (pH - 7.11, PaCO ₂ - 71.4 mm Hg, NSO ₃ - 21.4 meq / l) was noted. The oxyhemoglobin dissociation curve shifted to the right and down, and the shift was more pronounced than in patients with moderate severity (P ₅₀ was 33.3 mm Hg, the level of 2,3-DPH decreased to 6.1 mmol / L) . In accordance with the classification of Sukhinin-Luzhnikov (1966), the severity of the condition corresponds to the severe stage of acute poisoning with psychotropic drugs - the stage of deep coma 3B. The level of morphine in the patient's urine corresponds to a severe stage. After the administration of Naloxone at a dose of 1.6 mg intravenously, the patient's condition was practically unchanged. The patient remained unconscious, respiratory rate - 10 in 1 minute, blood pressure - 90/40 mm Hg, tachycardia - 120 in 1 minute. 30 minutes after the introduction of Naloxone in the study of the gas composition of blood RaO ₂ amounted to 47.1 mm Hg accordingly, the pH of arterial blood, PaCO ₂ remained unchanged. The position of the oxyhemoglobin dissociation curve has not changed. Given the ineffectiveness of specific antidote therapy, the persisting phenomena of respiratory failure, the patient was transferred to artificial lung ventilation. Detoxification therapy is carried out. Five hours later, the patient actively responds to the endotracheal tube. Mechanical ventilation terminated. In spontaneous respiration, there are no clinical manifestations of respiratory failure. The gas composition of the blood is within normal limits. The patient is extubated. After 36 hours, he was discharged home in satisfactory condition.

Techniques for performing the remaining examples with the claimed limit indicators are similar to those given. Examples of dissociation curves of oxyhemoglobin of varying severity of acute poisoning are shown in figures 1-3.

Thus, the invention allows to objectify the clinical classification data of Sukhinin-Luzhnikov.

The state of the hemoglobin dissociation curve (its shift to the right or left) characterizes the affinity of hemoglobin for oxygen and the ability of the latter to give oxygen to tissues, and a dynamic assessment of clinical indicators and additional laboratory data makes it possible to evaluate the effectiveness of antidote therapy and, if it is low, allows the indication for patient transfer for artificial lung ventilation.

Claims (1)

A method for assessing the severity of acute opioid poisoning, including assessing the degree of depression of consciousness, the degree of suppression of reflex activity and determining the presence or absence of complications from the respiratory system, characterized in that the gas and acid-base composition of the arterial blood is further determined with the subsequent construction of an oxyhemoglobin dissociation curve for for determining hemisaturation blood pressure and 2,3-diphosphoglycerate and with blood acidity 7.2 ± 0.05, oxygen tension in arterial blood levels 57.5 ± 1.1, the carbon dioxide voltage in arterial blood 58.7 ± 1.4 mm Hg, the concentration of carbonic acid anions in the blood 25.4 ± 0.2 meq / l, hemisphere pressure 28, 7 ± 0.5 mmHg and a content of 2,3-diphosphoglycerate 4.8 + 0.3 mmol / L, a mild degree of acute poisoning is diagnosed; with blood acidity of 7.35 ± 0.01, oxygen tension in arterial blood 55.1 ± 1.0, carbon dioxide voltage in arterial blood 64.1 ± 0.9 mm Hg, concentration of carbonic acid anions in the blood 35 , 4 ± 0.6 meq / l, hemisphere pressure of blood 33.9 + 0.5 mm Hg and the content of 2,3-diphosphoglycerate 7.4 ± 0.5 mmol / l, an average degree of acute poisoning is diagnosed, with a blood acidity of 7.11 ± 0.1, an oxygen tension in arterial blood of 45.1 ± 1.1, a carbon dioxide voltage in arterial blood 70.1 + 1.6 mm Hg, the concentration of carbonic acid anions in the blood 21.6 ± 0.2 meq / l, hemistaturation blood pressure 33.0 ± 0.7 mm Hg and the content of 2,3-diphosphoglycerate 6.4 ± 0.3 mmol / l diagnose a severe degree of acute poisoning.

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