Removal Effect And Prognosis Of Paraquat Concentration By Hemoperfusion

BackgroundThe mechanism of paraquat poisoning is complex and leads to multiple organ failure after poisoning.lt is difficult to treat patients with high mortality rate.In recent years,our rescue success rate has increased due to the accumulation of rescue experience and the mastery of the toxicological characteristics of paraquat,but the mortality rate of severe patients is still very high.The treatment scheme includes gastrointestinal cleaning,the use of hormones and immunosuppressive agents,and the elimination of toxins by hemoperfusion.Hemoperfusion is an important treatment for paraquat poisoning.There is no uniform standard for the frequency and intensity of hemoperfusion because of the lack of toxicant detection and it has greater randomness.Paraquat can sustainably cause organ dysfunction leading to pulmonary fibrosis and renal failure.Although hemoperfusion can reduce the concentration of paraquat,the prognosis of patients is quite different.The prognosis of patients was closely related to oral dose,digestive tract cleaning time and organ damage site.ObjectiveThe reasonable perfusion frequency was determined by the change of paraquat concentration after hemoperfusion and summarized and analyzed the adverse reactions,complications and prognosis of patients during perfusion to provide guidance for clinical treatment of paraquat.MethodThe clinical data of 79 patients with acute paraquat poisoning from July 2017 to July 2018 in the Emergency Poisoning Department of Qilu Hospital of Shandong University were collected,including 35 males and 44 females,with an average age of 37.8 +17.1 years.The patient was poisoned by 20%paraquat pesticide orally.The average dosage was 58.8±48.3 ml and the gastric lavage time was 6.7±6.1 hours.We treat patients with hemoperfusion,total digestive tract ablation,reduced glutathione,hormones and immunosuppressive agents.The patients received the first perfusion after admission,the second hemoperfusion after 6 to 8 hours,the third hemoperfusion within 48 hours and the fourth hemoperfusion within 72 hours.Quantitative detection of plasma paraquat concentration changes after perfusion and calculation of concentration decline rate to evaluate the efficacy of clearance.The changes of body temperature,heart rate,mean arterial pressure,pulse oxygen saturation and complications during perfusion were monitored.According to the rapid determination of the severity of paraquat poisoning by sodium dithionite method in urine,the patients were divided into three groups:mild,moderate and severe.The correlation between organ damage and poisoning degree was analyzed.The patients were divided into death group and survival group according to the 21-day discharge standard.The patients’age,sex,toxicity dose,gastric lavage time,perfusion frequency,PH value,lactic acid,APACHEII score,SIPP score,combined basic diseases,WBC,neutrophil count(N),neutrophil percentage(N%),lymphocyte count(L)and lymphocyte percentage were compared.Ratio(L%)was used to analyze the prognostic factors.Result1.Changes of plasma paraquat concentration before and after hemoperfusion:Hemoperfusion had obvious clearance effect on paraquat.The concentration of paraquat before 4 times of perfusion was 1.94±3.55ug/ml),0.80±1.43ug/ml,0.47±0.63ug/ml and 0.31±0.45ug/ml).After perfusion,the concentration of paraquat was 0.93±2.34ug/ml,0.36±0.64ug/ml,0.19±0.33ug/ml)and 0.09±0.19ug/ml.The difference was significant(P<0.05).2.Observation on the decrease rate of paraquat concentration before and after hemoperfusion:The concentration of paraquat decreased by 37.4±32.6%,50.5±39.5%,60.9±35.5%and 84.3±29.6%after single hemoperfusion,,and the total concentration decreased by 37.4(+32.6%),60.9(+37.0%),78.5(+25.1%)and 97.2(+5.1%)respectively.The decrease rate of paraquat concentration was significant after hemoperfusion(P<0.05).3.Observation of vital signs during hemoperfusion:Before perfusion,the body temperature of the patients was 36.7±0.58℃ and SPO2 was 96.9±2.1%.There was no significant change during perfusion(P>0.05).Before perfusion,the average heart rate was 86.0±11.2/min),the average arterial pressure was 95.6±12.5 mhg),the heart rate increased to 90.5±12.2/min)and the average arterial pressure decreased to 75.1±8.Ommhg)after 30 minutes of perfusion.The difference was statistically significant(P<0.05).4.Observation of complications during blood purification:There were 4 cases of hemodynamic disorder,2 cases of femoral vein thrombosis,2 cases of filter coagulation.1 case of catheter bleeding failure,1 case of subcutaneous hematoma and 1 case of allergic reaction during blood purification.No complications such as filter rupture,catheter-related blood flow infection,shiver and arrhythmia occurred.5.Observation on the correlation between degree of poisoning and organ damage:There were significant differences in liver function impairment between mild and severe patients(P<0.05);Compared with mild patients,there was a significant difference in pulmonary fibrosis between moderate and severe patients(P<0.05).Compared with mild patients,moderate and severe patients had significant impairment of renal function(P<0.05).The proportion of severe patients with cardiac or nervous system damage was significantly higher than that of mild and moderate patients(P<0.05).6.Comparison of survival group and death group:There was no significant difference in age,sex,gastric lavage time,perfusion frequency and the proportion of basic diseases between survival group and death group(P>0.05).The PH value,lactic acid,APACHEII score,SIPP score,oral dose,intestinal washout time,white blood cell count(WBC),neutrophil count(N),neutrophil percentage(N%),lymphocyte count(L%)and lymphocyte percentage(L%)in survival group were significantly different from those in death group(P<0.05).Conclusion1.Hemoperfusion can significantly reduce the plasma paraquat concentration.After four times of perfusion,the drug concentration dropped to a safer range.Repeated hemoperfusion within 24 hours has significant effect and can provide treatment basis for follow-up rescue.2.Hemodynamics was greatly affected within 30 minutes after hemoperfusion.Interventions such as slowing down blood flow and rehydration could improve symptoms,but had no significant effect on body temperature and SPO2.3.The complications of blood purification,such as thrombosis,coagulation,obstruction of catheter,subcutaneous hematoma and allergic reaction should be prevented and treated in time.4.The proportion of organ damage is correlated with the degree of poisoning,and the location of organ damage is important for prognosis.5.The PH value of blood gas,lactic acid,APACHEII score,SIPP score,oral dose,intestinal washout time and peripheral blood cell count were closely related to the prognosis of patients.