中国科技论文统计源期刊 中文核心期刊  
美国《化学文摘》《国际药学文摘》
《乌利希期刊指南》
WHO《西太平洋地区医学索引》来源期刊  
日本科学技术振兴机构数据库(JST)
第七届湖北十大名刊提名奖  
医药导报, 2017, 36(6): 709-710
doi: 10.3870/j.issn.1004-0781.2017.06.029
1例曼陀罗中毒的药学监护
钮佳丽1,, 丁云龙2, 卢通1, 薛婷1, 居峰1, 赵广玉1,

摘要:

目的 总结临床药师参与曼陀罗中毒的救治及药学服务的体会。方法 通过参与1例曼陀罗中毒患者的药物治疗实践,分析曼陀罗中毒患者住院期间的诊断、治疗方案,对患者进行用药监护。结果 临床药师协助医师诊断,参与药物治疗全过程并进行药学服务,患者治疗3 d后病情得到有效控制。结论 临床药师通过药学服务,可协同临床优化治疗方案,提高药物疗效,减少不良反应,提高患者用药依从性,促进临床合理用药。

关键词: 临床药学 ; 曼陀罗 ; 中毒 ; 药学监护

Abstract:

曼陀罗为茄科植物[1],是一种含生物碱类有毒植物,主要成分为莨菪碱、阿托品和东莨菪碱[2],世界范围内均有曼陀罗种植及中毒的报道[3],误诊是曼陀罗中毒治疗中最大的障碍。我院临床药学室与神经内科共同诊治1例拟诊醉酒后确诊曼陀罗中毒病例,现将诊断过程、治疗用药结合文献复习汇报如下。

1 病例概况

患者,男,58岁。因“饮酒后出现神志模糊、胡言乱语3 h”,于2015年2月20日17∶21以“乙醇中毒”收住我院神经内科。患者入院当天约12∶00饮酒约100 mL,于14∶00出现神志不清、胡言乱语,一直未解小便,症状持续不缓解,入我院就诊。入科体检:血压140/100 mmHg(1 mmHg=0.133 kPa),神志模糊,答非所问,仅能说出自己姓名,双侧瞳孔等大等圆,直径5.0 mm,对光反射迟钝,双手不自主活动,颈软,心率120 次·min-1,四肢肌力检查不合作,可见随意活动,生理反射存在,病理反射未引出。行头颅CT检查示“双侧基底节腔隙灶”,检查途中恶心、呕吐2次,为胃内容物,伴少许咖啡样液体,非喷射状。心电图示窦性心动过速。患者既往有“窦性心动过缓”病史15年,吸烟、饮酒30年。

当日少量饮酒,不足以导致严重意识障碍,需寻找其他可能导致意识障碍的诱因。医师于2015年2月20日19∶00联系临床药师会诊协助治疗。

2 主要治疗经过与转归

患者所饮酒为绵竹大曲含有多种浸泡物,家属诉该酒已浸泡20余年,临床药师检查酒中浸泡物,其中一种为曼陀罗,结合患者瞳孔散大、心跳过速、排尿困难、血压升高、躁动等精神症状,支持曼陀罗中毒诊断明确。医嘱予以新斯的明1 mg肌内注射,并给予泮托拉唑。当日夜间患者神志不清,胡言乱语,有时自言自语,双手不自主活动,予吸氧,新斯的明,地西泮及地塞米松对症治疗,症状缓解。2015年2月21日晨患者神志清,双手不自主活动缓解,无呕吐,无四肢抽搐。体检:血压 114/61 mmHg,神志清,双眼球活动可,双侧瞳孔等大等圆,直径约4 mm,对光反射迟钝,颈软,双肺呼吸音清,心界无扩大,心率79次·min-1,心律齐,未闻及杂音。治疗3 d后,患者神志清,体温正常,一般情况良好,无特殊不适,出院。嘱患者注意休息,戒烟少酒,避免饮用含有不明浸泡物的酒品。患者药物治疗方案见表1。

表1 患者药物治疗方案
药物名称 剂量 途径 频次
新斯的明 1.0 mg 肌内注射 prn
泮托拉唑 40 mg 静脉滴注 qd
地塞米松 5 mg 静脉滴注 qd
地西泮 10 mg 肌内注射 prn
5%葡萄糖注射液 250 mL 静脉滴注 qd
果糖氯化钠 500 mL 静脉滴注 qd
维生素C注射液 2 g 静脉滴注 qd

表1 患者药物治疗方案

3 药学监护
3.1 解毒药的应用

曼陀罗中毒表现为M-胆碱受体阻断症状,可选用M胆碱受体激动药或抗胆碱酯酶药解救。临床医师予以新斯的明肌内注射拮抗治疗,每次1.0 mg,根据病情每30~60 min给药1次,24 h内剂量不超过5 mg。患者次晨生命体征平稳,神志清,瞳孔恢复正常,治疗安全有效。

新斯的明是胆碱酯酶抑制药,为季铵类化合物,是毒扁豆碱的人工合成代用品。新斯的明进入机体后,通过可逆性抑制胆碱酯酶活性,使乙酰胆碱不能水解,从而提高体内受体部位的乙酰胆碱浓度,加强和延长乙酰胆碱的作用,呈现出全部胆碱能神经兴奋的效应。临床药师严密监测患者瞳孔、意识、呼吸、血压、排尿、胃肠道反应等情况,以免患者用药不足或过量。

3.2 镇静药物的应用

躁狂患者适量应用镇静药,但忌用吗啡或长效巴比妥类,以防增加中枢神经的抑制作用,苯二氮芯卓类治疗有效[4]。苯二氮芯卓类安全范围大,不良反应少见,还具有明显的抗焦虑、镇静作用,几乎已完全取代传统的镇静催眠药如巴比妥类、水合氯醛等。因患者饮酒,乙醇可增强中枢抑制作用,临床药师建议医生予小剂量地西泮镇静,医师采纳,并嘱护士肌内注射地西泮时速度宜缓慢,以防造成心血管与呼吸抑制。

3.3 补液促排、抗氧化

早期大量补液,同时静脉滴注葡萄糖溶液,可促进毒物排泄[3]。使用利尿药、维生素C促进代谢。另外维生素C参与体内氧化还原反应,是体内重要的抗毒物质,大剂量的维生素C可增加抗毒能力。临床药师观察患者尿量情况,及时与医师沟通,适当进行调整。

临床药师根据药物的药理作用及可能产生的药物不良反应制定监护计划,进行用药监护,包括疗效的监护和药物不良反应的监护,重点监测患者解毒剂的用法用量及患者瞳孔、神志的变化。治疗3 d后,患者神志清,体温正常,一般情况良好,治疗安全有效。患者用药顺利,治疗期间未出现药疹、恶心、呕吐、呼吸抑制等药物不良反应。

4 结束语

临床药师参与1例曼陀罗中毒患者的药物治疗,在临床实践中协助医师诊断、处理药物中毒救治工作。结合患者病史、临床表现,提出药物治疗方案的建议,对患者进行用药监护及教育,提高药物疗效,减少了不良反应,提高患者用药依从性,促进临床合理用药。

随着人们的生活水平和认识的提高,误食曼陀罗中毒的病例在减少,但不乏部分人群以产生欣快感为目的而私自服用曼陀罗的报道[5-7],因其较高的误诊率及可能不良后果,提高对曼陀罗中毒的认识非常有必要。

The authors have declared that no competing interests exist.

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[本文引用:1]
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关键词(key words)
临床药学
曼陀罗
中毒
药学监护


作者
钮佳丽
丁云龙
卢通
薛婷
居峰
赵广玉