You are on page 1of 14

Paraquat (thuc c chy) l mt ho cht dit c cc k nguy him cho ngi v t vong cao

T ngy 1/10 ti ngy 10/11/2010, Khoa Cp cu Bnh vin Ch Ry, TP H Ch Minh tip nhn 18.200 ca cp cu, trong 504 ca t t v ng c. Ring ng c thuc bo v thc vt chim 203 ca. Trong c 150 ca(8 ca di 16 tui, 78 ca di 24 v 43 ca trong tui t 25 ti 35), bnh vin c thng bo nn nhn c s dng chai thuc dit c "mu xanh" - Paraquat. Mi ln ch cn nghe cu thng bo n gin trong vi v ca ngi nh bnh nhn l cc bc s cp cu c nh b "in git" bi ci chai "mu xanh" lm h phi b tay trong 41 trng hp (5 ca cht trong khi cp cu, 36 ca t vong khi ang iu tr). Nhng cha ht, cn ti 22 ca do bin chng suy h hp buc phi cho v coi nh cng t vong.

Tn IUPAC 1,1 '-dimethyl-4, 4'-bipyridinium dichloride

Cng thc phn t Khi lng phn t

C 12 H 14 Cl 2 N 2 257,16 g / mol

im nng chy Nhit si

177175-180 C [1] > 300 C [1]

ha tan trong nc

cao

Paraquat l tn thng mi ca 1, 1 '-dimethyl-4, 4'-bipyridinium dichloride, mt trong nhng cht dit c c s dng rng ri nht trn th gii. Paraquat, mt cht quan trng nht trong nhng cht dit c bipyridyl (paraquat, diquat, chlormequat, difenzoquat and morfamquat), git cht t bo thc vt khi tip xc mt cch nhanh chng v khng chn lc. N c hi i vi con ngi v ng vt, v c lin quan n vic pht trin ca bnh Parkinson. Paraquat bin tnh hon ton khi tip xc vi t. Pyridin c kt hp vi natri trong amoniac khan cho 4,4 '-bipyridine, sau c methyl ha vi chloromethane cho cc hp cht mong mun. Lch s pht trin

Mc d ln u tin tng hp vo nm 1882, c tnh dit c ca paraquat khng c cng nhn cho n nm 1955. Paraquat ln u tin c sn xut v bn ra bi ICI (nay l Syngenta AG - mt cng ty ton cu ca Thy S kinh doanh cc sn phm nng nghip c bit l ht ging v thuc tr su) vo u nm 1962, v ngy nay l mt trong s nhng cht dit c thng c s dng nht. Lin minh chu u cp php cho paraquat vo nm 2004. Thy in cng s h tr ca an Mch, o v Phn Lan, a y ban Lin minh chu u ra ta. Ngy 11/7/2007, ta n bi b cc vic cp php cho paraquat nh mt cht bo v thc vt. Thuc tr c

Paraquat c s dng nh mt loi thuc dit c amoni bc bn, mt trong nhng cht dit c c s dng rng ri nht trn th gii. Tc dng nhanh, khng chn lc, v git cht t bo thc vt khi tip xc.N c phn phi li trong thn cy, nhng khng gy hi v cy trng thnh. Paraquat c ch quang hp, bo v cy trng bng cch kim sot c di. Ti Hoa K , paraquat ch yu c "hn ch s dng", ngha l n c th c s dng khi c cp php. Lin minh chu u , paraquat b cm t 11/7/2007. T t Phn ln (93%) t vong do ng c paraquat l c , hay t t. Ti cc nc th gii th ba , paraquat l mt "tc nhn t t chnh". V d, Samoa 1979-2001, 70% cc v t t do s dng paraquat.Ti min nam Trinidad 19961997, 76% cc v t t l do paraquat. Paraquat tr thnh tc nhn t t c s dng rng ri cc nc th gii th ba l tnh sn c ca n, liu c thp (10 ml hoc 2 mung c ph l gy t vong) v chi ph tng i thp. c cc chin dch kim sot hoc thm ch cm paraquat hon ton, v c nhng ng thi hn ch tnh sn bng cch gio dc ngi dng. c tnh Paraquat l mt cht c c hiu nht vi phi c bit n. T l t vong do ng c cao, hin nay cn khong 130 nc khc vn cho php s dng paraquat, nhiu nc cm hoc hn ch s dng cht ny. Nht Bn hng nm c hn 1000 ngi cht do ung paraquat, iu ny dn n vic chnh ph nc ny nm 1986 cm s dng paraquat nng 20%. Ng c Paraquat cho ti nay ch c th iu tr triu chng v nng .

ng tiu ho paraquat c hp thu rt nhanh nhng t (5-10%). Hp thu ch yu rut non. Khi d dy rut b tn thng lan rng, s lng cht c c hp thu s tng ln. Paraquat khng gn vi protein huyt tng. Nng nh ca paraquat trong huyt tng t c trong vng 2 gi sau ung. Tip xc qua da, hp thu vo c th ni chung ch xy ra khi tip xc ko di hoc da b tn thng. Trong hon cnh ngh nghip hoc nng nghip, tip xc vi paraquat qua ng h hp khng khng lm cho lng paraquat c hp thu n mc gy nhim c. Bi v kch thc cc ht cha paraquat trong khng kh ln (hu ht trn 5mm) lm cho paraquat khng i sau c xung ng h hp cho hot ng hp thu xy ra. Ngi ta thng bo mt trng hp t vong do ng c paraquat qua ng m o. Mt tip xc vi paraquat s b tn thng nhng nu n thun th khng gy nhim c ton thn Paraquat, khi ung vo, rt c i vi ng vt c v, bao gm c con ngi, dn n hi chng suy h hp cp ( ARDS ), v khng c thuc gii c c hiu. Tuy nhin, fuller's earth (t st) hoc than hot tnh c hiu qu nu c s dng ng lc. T vong c th xy ra 30 ngy sau khi ung. Paraquat c pha long khi phun t c hi, do , nguy c ln nht b ng c thuc l trong qu trnh pha trn v vn chuyn paraquat s dng. Trong cc nghin cu c tnh cp tnh bng cch s dng ng vt trong phng th nghim, paraquat c chng minh l c c tnh cao bng ng ht v c xp loi c loi I (cao nht trong bn cp ) cho cc nh hng cp tnh ln ng h hp. Tuy nhin, EPA xc nh rng cc ht c s dng trong nng nghip (400-800 m) l vt ra ngoi phm vi ht vo v do gy c kiu ny khng phi l mi quan tm. Paraquat l c hi (loi II) bng ng ming v c hi (loi III) theo ng da. Paraquat s gy kch ng mt trung bnh n nng v kch ng da ti thiu, v c t trong c loi II v IV (hi c) tng ng cho cc nh hng ny. Ngay c mt ung mt ln duy nht, ngay lp tc nh ra, c th gy ra ci cht do x phi, dn n ngt. Theo Trung tm kim sot dch bnh Hoa K, ung paraquat gy suy gan, phi, tim v thn trong vng vi ngy n vi tun, c th dn n t vong trong 30 ngy sau khi ung. Nhng ngi b phi nhim ln khng c kh nng sng st. Phi nhim kinh nin c th dn n tn thng phi, suy thn, suy tim, v hp thc qun. T vong do tai nn v t t t khi ung paraquat l tng i ph bin. Phn b Ngoi mt, paraquat phn b nhanh chng nht ti phi, thn, gan v c. Th tch phn b ca paraquat l 1,2 1,6L/kg.

Paraquat t c nng cao v tn ti lu trong phi, nng trong phi c th cao hn so vi nng huyt tng gp 50 ln. Sau ung 5-7 gi, nng paraquat trong t chc phi t cao nht khi chc nng thn bnh thng. Paraquat c cc ph bo type I v II hp th m khng ph thuc bc thang nng . Hin tng ny xy ra theo c ch vn chuyn tch cc ph thuc ATP. S lng paraquat huyt tng cn t n mt ngng ti hn cho qu trnh hp th phi din ra. Paraquat qua c nhau thai, trong mt nghin cu, nng paraquat trong dch i v mu dy rn, bo thai cao hn nng trong mu ngi m 4-6 ln. Khng c bo thai no sng st. Tuy nhin nu ngi m tip xc vi paraquat cn sng th n ln c thai sau khng nguy him n bo thai. Chuyn ho, thi tr Paraquat c o thi hu nh hon ton qua thn nh c qu trnh lc ca cu thn v qu trnh bi tit tch cc ca ng thn. Trong vng 12 - 24 gi sau ung, trn 90% paraquat c o thi di dng khng i qua thn, nu chc nng thn bnh thng. Tuy nhin c th xt nghim thy paraquat trong nc tiu vi ngy sau do c s ti phn b paraquat t cc c quan. Na i sng ca paraquat c th ko di 12-120 gi hoc lu hn khi c suy thn. LIU C CA PARAQUAT Ung 2 - 4 gram hay 10 - 20ml l dung dch 20% paraquat (1ngm) dn n t vong ngi ln. Tuy nhin ch cn ung 1 - 2gram (5 - 10ml dung dch 20%) th hu ht bnh nhn cng s t vong. Liu 4-5ml s t vong tr em. Nhiu thc n trong d dy s gim s hp thu c cht. Than hot hay t st ung ngay vo s hp ph paraquat, lm gim c. NHN BIT NG C PARAQUAT NGI Nhn dng ho cht: Paraquat hin nay xut hin nc ta vi nhiu sn phm thng mi khc nhau nh: Gramoxone 20 SL, Agamaxone 276 SL, Alfaxone 20 SL, BM - Agropac 25SL, Camry 25 SL, C chy 20 SL, Danaxone 20SL, Forxone 20SL, Hagaxone 20 SL, Heroquat 278 SL, Nimaxon 20 SL, Paraxon 20 SL, Pesle 276 SL, Tho tuyt 20 AS, Tungmaxone 20 SL. Trong Gramoxone l sn phm thng mi ph bin nht vi dung dch nng paraquat 20%. c im chung ca cc sn phm ny l dng l nha ng dung dch mu xanh lam. Liu gy c trung bnh (LD 50) l 35 mg/kg. Sau khi ung s c hp thu nhanh chng ng tiu ha (5-10%), sau khong 2 gi t nng cao nht trong mu. Paraquat trong mu s c phn b n hu ht cc c quan trong c th, tn thng ch yu thng gp l gan, thn v phi. Tn thng gan, thn xut hin 2-3 ngy sau ng c, l tn thng c th hi phc. Biu hin tn thng gan l vng da, tng cc transaminase, tng bilirubin ch yu l bilirubin trc tip. Tn thng thn vi thiu niu, suy thn cp, tng ur v creatinin mu. Tn thng phi xut hin mun hn, 5-10 ngy sau ng c, phi l c quan b tn thng nhiu nht v t bo ch l t bo ph nang tp 2, biu hin lm sng kh th, th nhanh, tm ti do x phi, tn thng phi thng khng hi phc v c din tin t vong. Sau khi ung dung dch, nc c paraquat: xut hin cm gic nng bng ming, hng, gi mc hay lot hng ming (c th nhn thy). Nn, bun nn, au bng kh chu, c th bng thc qun, lot trt d dy rut (bng kim) nu ung m c (d thng, hay trn kh mng phi). Nhanh chng dn n i t, v niu, suy thn cp, hoi t c, sc v t vong trong vi gi hay vi ngy. Nu ung 1-2g c th sng qua mt s ngy ri suy h hp do x phi (phi trng hai bn) v cng dn n t vong.

Cc cht thi ca ngi ng c paraquat: sau khi n, ung nn ra dch mu xanh. Bnh sinh Paraquat tri qua chu trnh xy ho/kh cng vi NADPH v xy dn ti hnh thnh gc superoxide (O2 ). Bipyridyls c hai ion dng b NADPH kh thnh cc gc t do c mt ion dng v theo chu trnh tr v dng ban u ca chng bng vic cho xy mt in t hnh thnh gc superoxide (hnh). Trong giai on u ca chu trnh ny, paraquat hai ion dng (PQ 2+) cng vi NADPH tri qua mt phn ng to ra ion paraquat b kh (PQ1+) v NADP+. PQ1+ phn ng hu nh ngay lp tc vi xy ti to li PQ2+ v gc superoxide. C sn NADPH v xy, chu trnh xy ho-kh ca paraquat xy ra lin tc, vi vic NADPH lin tc b mt i v khng ngng to ra gc superoxide. Gc t do superoxide sau phn ng vi bn thn n to ra peroxide hydro (H2O2), v vi H2O2 + st to thnh gc t do hydroxyl (OH). Chu trnh xy ho-kh lin quan n paraquat, xy, NADPH cng nh l vic sau to thnh gc t do hydroxyl dn ti nhiu c ch lm tn thng t bo. Cn kit NADPH dn ti cht t bo. Cc gc t do hydroxyl c c tnh cao v phn ng vi lipid trn mng t bo, y l mt qu trnh hu hoi c bit vi tn gi l peroxide ho lipid. DNA v cc protein ti cn thit cho t bo sng st cng b cc gc t do hydroxyl ph hu. Hu qu ln t bo do vic hnh thnh cc gc t do (superoxide v cc gc t do khc) l i tng ca rt nhiu cc ti liu trong y hc. Ngi ta tin hnh cc th nghim iu tr nhm vo vic thay i cc gc t do bng cc cht nh desferioxamine, superoxide dismutase, alpha-tocopherol v vitamin C cng vi bi niu cng bc. Khng may l cho n hin nay khng c cht no trong s ny c khuyn co dng. Mc d chi tit y v c cht hc ca cc gc t do do paraquat sinh ra vn cha c bit nhng nhng g ngi ta bit v c s ng c l s tng tc gia paraquat, NADPH v xy. Sau , mc t bo, oxy l yu t ti cn thit cho vic hnh thnh bnh l do paraquat. y l c s cho vic hn ch cung cp xy trong vic iu tr ban u bnh nhn ng c paraquat. Bipyridyls c tnh n mn v gy tn thng ging nh kim khi tip xc vi da, mt v cc nim mc. Cc c quan ch ch yu trong ng c ton thn paraquat l ng tiu ho, thn v phi. D dy rut b tn thng nng n do tc dng n mn trc tip khi bnh nhn ung paraquat c ch vi nng cao. Thn l c quan o thi paraquat v c nng cao hn so vi cc c quan khc. Paraquat c phi n nhn tch cc nh qu trnh ph thuc nng lng. Gii phu bnh: Sau khi tip xc vi paraquat, phi tri qua mt kiu tn thng 2 giai on. Giai on ph hu c trng bi hu hoi biu m ph nang do hu qu ca chu trnh xy ho kh. Sau l giai on tng sinh, c coi l k tip ca giai on hu hoi, giai on ny gy hu hoi thm. Trong giai on 2, cc t bo biu m bnh thng b thay th bi t chc x, dn ti x phi t, thiu xy v t vong. ngi, chut, ch b ng c paraquat, m t thi cho thy phi b ph v xut huyt, xut huyt khong gia cc ph nang, xung huyt v x phi. Tn thng mng t bo ph nang dn n vim ph nang, hu hoi t bo ph nang, thm nhp cc t bo x, sau phi b mt tnh n hi, hot ng h hp b gim, trao i kh km hiu qu. Trn ng vt b ng c, thng khng thy cc tc dng ngay lp tc, tuy nhin trong vng 10-14 ngy, bnh nhn b suy h hp, cc thay i hnh thi bao gm thoi ho v hnh thnh cc khng bo cc ph bo, tn thng vi cc t bo biu m ph nang type I v II, hu hoi mng biu m, tng sinh t bo si. Gan b hoi t trung tm tiu thu, thn b hoi t ng thn, cu thn. Trng lng phi ca con vt tng ng k nhng cn nng ton thn ca con vt li b gim. Xt nghim nhanh

Ly 10ml nc tiu bnh nhn (hoc 10ml nc c nghi paraquat). Cho vo 2ml dung dch natri dithionite 1% vi dung dch NaOH 1N. Xut hin mu xanh t nht da tri n xanh mc cu long chng t c paraquat nng t thp n cao. Ng c paraquat c th c chia thnh 3 bnh cnh lm sng tu thuc vo s lng paraquat Ng c nng: Ung ion paraquat vi s lng ln hn 40mg/kg dn ti suy a ph tng tin trin nhanh chng (tng ng vi mt ngi 70kg nu ung 14 ml dung dch 20%). Cc triu chng sm bao gm tn thng ti ch vi ng tiu ho, bao gm c thc qun. Lc u bng ming hng, hoi t v bong nim mc ming, hng, vim d dy rut nng vi tn thng thc qun, d dy. Bnh nhn nn nhiu, au bng, chy mu ng tiu. Cc bin chng ca giai on sm ny gm trn kh mng tim, trn kh trung tht v trn kh mng phi. H hp: kh th, ho, suy h hp tin trin. Tn thng thn bao gm hoi t ng thn, cu thn, xut hin r sau 24 gi, biu hin protein niu, t bo v tr, tng ur, creatinin mu, thiu niu, v niu. Trong mt nghin cu, suy thn bo hiu mt tin lng xu, 95 % (19/20) bnh nhn c suy thn t vong. Thng thn/gan: gii phu bnh thy hoi t v thng thn, tn thng gan biu hin sm vi tng bilirubin, AST, ALT, suy gan. Tim mch: in tim thay i t nhp nhanh xoang n cc lon nhp tht, suy tim. Thn kinh: Hn m, ph no, co git, xut huyt v no, thn no. Mu: tng bch cu, DIC. Giai on sau, tu xng b c ch biu hin bng thiu mu, gim tiu cu v gim bch cu. Bnh nhn b hoi t c lan rng, hoc suy tu, c th t vong trong thi gian tnh bng gi ti ti a l vi ngy, thng do sc tim. Ng c trung bnh Ung paraquat vi s lng t 20-40mg/kg gy mt bnh cnh m thm hn. Cc triu chng ti ch da, nim mc tin trin t t hn. Phi: Suy h hp tin trin nng dn. Lc u, trong vng vi ngy u phim xquang phi bnh thng, sau , sang giai on tn thng th 2, thm nhim v m hai bn phi. Tn thng thn, suy thn tin trin nng dn v c th dn ti tng creatinin nhanh mt cch khc thng khng tng ng vi tng ur mu (t l BUN/creatinin thp). Trong mt trng hp cc tc gi quan st thy gi tr creatinin tng cao bt thng khi so vi gi tr ur mu v bnh nhn b xut huyt tiu ho trn (l ra tng cao ur ch khng phi creatinin), iu ny gip tc gi chn on ng c paraquat mc d bnh nhn ph nhn vic ung paraquat.

Cui cng vi cc trng hp bnh nhn ung paraquat vi s lng trung bnh, hin tng x phi xut hin sau nhiu ngy n nhiu tun. a s cc bnh nhn ung 20-40mg/kg ion paraquat s t vong. Ng c nh Ung ion paraquat vi s lng di 20mg/kg khng gy triu chng g hoc ch cc triu chng nh ng tiu ho. Tt c cc trng hp nh vy c hy vng hi phc hon ton. Tc gi Bismuth coi liu di 30mg/kg l lnh tnh, 30-50mg/kg c th gy ng c trung bnh v trn 55mg/kg l gy t vong. Mc d nguyn nhn ca hu ht cc trng hp b ng c nng paraquat l tip xc ng ung hoc tim, nhng mc ng c nng hoc gy t vong c th do tip xc cc ng khc. Tip xc qua da c th dn ti t vong khi tip xc ko di hoc theo cch khc thng vi BHs dng m c. c cc trng hp t vong do ng c paraquat khi bnh nhn bi cht ny ln ru v tc dit try hoc bi ton thn (tr mt) cha gh. C nhiu thng bo t vong do ng c paraquat khi ngi ta nhng cht ny m c ln qun o v mc trong thi gian ko di. Tip xc vi paraquat qua da vi nng long theo ng hng dn hoc vi dng m c nhng trong thi gian ngn th khng gy ng c ton thn. Mt tip xc vi paraquat m c s b tn thng n mn ph thuc vo thi gian tip xc v nng . Ti California, cng ng dn c tip xc vi mi trng b nhim paraquat biu hin rt nhiu triu chng ti ch v mt s triu chng ton thn, bao gm ho, a chy, au u, mt mi, chy nc mi, chy nc mt nhiu. Cc triu chng ny tng ng k khi so vi nhm cng ng lm chng. Tip xc trong ngh nghip do bt cn c th gy kch ng nim mc, vim kt mc, gic mc, chy mu mi v au hng. Biu hin lm sng ca ng c cc thuc tr c nhm bipyridylium v chn on phn bit vi cc cht c th gy triu chng ng c tng t.

Suy thn cp

X phi

Suy a tng

Nn nhiu/a chy + Xut huyt tiu ho trn Thuc chng ung th Bari Acid boric Carbamate Cc glycoside tim

Acetaminophen Cc aminoglycoside Amphotericin B Arsine Khng sinh Beta-lactam Acid boric/cc borate Cisplatin Cyclosporine Diethylene glycol

Nhm Amiodaron(dng lu) Thuc chng ung th: Bleomycin Cyclophophamide

Abrin (rosary pea) Colchicine Fluorides Fluoroacetate (hp cht 1080) I t

Nhim aming St Berylium Kim loi: Crm Asen Vng Bari

Cc cht n mn Colchicine Ethanol Fluoride

Dinitrophenol Ethylene glycol Hydrocarbon c clo Kim loi: Arsen Cadmium Crm ng Thu ngn (mui) Thalium Thuc chng vim khng steroid Phosphine

Kaolin Nitrofurantoin (dng lu) Ozone Phosgene Silica (bi phi) Bt talc Tocainide

Crm(mui ho tr 6) Thu ngn (mui) Phosgene Phosphine Ricin (caster bean) Cc salicylate Phosphua km

I t St Metaldehyde Kim loi: Asen Crm Thu ngn Thic hu c Thalium n nm , cy c Nicotine Hi chng cai opiate Phospho hu c

Phosphorus Paraldehyde Polymyxin Phenol Cc thuc cn quang Phosphorus Cc sulfonamide Podophyllin Vancomycin Salicylate Theophylline Clorua km Phosphua km

iu tr: Nhiu bin php iu tr ng c ton thn do cc thuc tr c nhm bipyridyl da trn bnh sinh ca cc tc nhn ny nhng khng may l hu ht cc bin php ny u khng cho thy c hiu qu. thi im bnh nhn n gp thy thuc th hu qu cui cng c xc nh bi mc tip xc. Tuy nhin, cc bin php iu tr h tr c th cn thit cc bnh nhn c tin lng tt v vn nn c p dng cho cc bnh nhn c tin lng ti.

Bao gm: Kim sot ng h hp v h tr chc nng sng nng cao khi cn. Loi b cht c: D dy rut: than hot a liu, 1g/kg ung. Da v mt: ra bng nhiu nc. Truyn dch tinh th m bo lu lng nc tiu 1-2ml/kg/h. xy: chi cung cp khi c thiu xy. Gim au v an thn nu cn. Loi b cht c bng bin php thay th thn: Lc mu hp ph: cn tranh ci, c l khng lm thay i kt qu cui cng. Thn nhn to ch khi c suy thn. Bi niu cng bc hoc lc mng bng khng c tc dng Loi b cht c: Mc d loi b cht c qua ng tiu ho cha bao gi c chng minh l thay i c kt qu cui cng ca ng c cc thuc tr c nhm bipyridyl nhng nu thc hin sm c l l mt bin php c gi tr nht hin nay trong cc trng hp tip xc ng tiu ho. Fullers earth v bentonite clay tng c a vo danh sch thuc cc tc nhn c la chn nhng than hot d kim hn v c l cng hiu qu khng km. Cn dng than hot 100g vi ngi ln v 1g/kg cho tr em tr khi c chng ch nh nh nn nhiu khng kim sot c hoc bng nng nim mc ming. Dng than hot a liu cha c nghin cu trong ng c cc thuc tr c nhm bipyridyl tuy nhin cch dng than hot ny s khng c hi mt khi nn c kim sot tt. Dng tng cng 3 liu, mi liu cch nhau 2 gi. Fullers earth c dng dng dung dch treo (15 hoc 30%), ngi ln dng 100-150gam, ung nhiu ln cho n khi thy bnh nhn i tin ra thuc, liu tr em 1-2g/kg. Bentonite clay 100-150gam, tr em 2g/kg (pha dung dch treo 7%). Sodium polystyrene sulfonate (SPS) (Kayexalate(R)): cn c thm cc nghin cu trc khi khuyn co dng thuc ny. Trn th nghim, thuc c kh nng hp ph cao hn than hot gp 15 ln. Liu dng cao hn nhiu so vi dng trong iu tr tng kali mu. Vic cc thuc tr c nhm bipyridyl c hp thu nhanh chng v kh nng tn thng ng tiu ho do n mn cng nh thiu bng chng cho thy hiu qu khin cho ra d dy, syro ipeca hoc ra rut ton b khng th hin c vai tr. Ipeca c th c ch trong hon cnh gia nh nu p dng ngay lp tc. Cn cn nhc nguy c nng thm tn thng ng tiu ho vi s lng thuc tr c bnh nhn ung. Ra d dy c th c gi tr nu c lm sm trong vng 1 gi nhng cn phi cn nhc vi nguy c thng ng tiu ho. Trong cc bnh nhn ng c paraquat v diquat do c m tc gi gp, ngi sng st duy nht l mt nng dn t t bng cch ung paraquat nhng ng thi v tnh cng n mt ba n ln ln cui cng bng mt loi bnh

a. Bnh nhn ny sau nn t nhin v n khoa cp cu trong vng 5 pht sau ung, than hot c dng ngay, sau c ra d dy v sau tip tc c dng than hot. Tip xc qua da v mt cn c x tr bng ra nhiu nc. Khi tip xc qua mt, cn theo di pH v ra ti khi pH tr v bnh thng. Loi b cht c bng bin php thay th thn: V nng nh ca paraquat trong mu t c sau ung 2 gi, trong vng 4 gi sau ung, paraquat khuch tn vo cc t bo biu m ph nang, tt c cc bin php nhm tng thi tr paraquat u phi c bt u tin hnh cng sm cng tt. Lc mu hp ph qua ct than hot l mt bin php iu tr cn tranh ci trong iu tr ng c cc thuc tr c nhm bipyridyl c th gy t vong. Da trn l thuyt l paraquat mc d i vo phi nhanh chng, nhng th tch phn b 1,2-1,6L/kg v gn vi protein km nn nhiu tc gi c gng tin hnh lc mu hp ph, hemodialysis, bi niu cng bc trc tip loi b cht c min l tin hnh rt sm hoc nng paraquat trong mu thuc ng gianh gii t vong. Widdop gy c paraquat cho ch vi liu thp 10mg/kg, sau lc mu hp ph trong vng 6 gi sau ung thy ci thin t l t vong. Hampson th nghim trn ch thy tt c con vt b ng c paraquat vi liu gy cht khi c lc mu hp ph sau ung 12 gi u cht bt k thi gian lc ko di bao lu, ch 50% trong s cc con vt c lc mu trong vng 2 gi sau ung mi sng st. Do nu lc mu sau 6 gi, t l t vong khng c ci thin. Suzuki lc mu hp ph tch cc (ngy u tin lc lin tc 10 gi hoc hn) trn 40 bnh nhn trong vng 15 gi sau ung paraquat thy c ko di thi gian sng ca bnh nhn nhng khng ci thin t l t vong. Mc d Okenek v cc cng s chng minh thanh thi ca paraquat tng ln khi lc mu hp ph qua ct than hot trn chut v cc tc gi ny mnh m ng h bin php ny nhng thng nht hin nay l lc mu hp ph khng lm thay i kt qu cui cng. Mc d lc mu hp ph qua ct than hot c th lm tng thi tr cc thuc tr c nhm bipyridyl nhng tin lng khng thay i. iu ny bi v t nht c 3 yu t: (1) bnh nhn thng ung liu cao gp nhiu ln liu cht, (2) khng c cch no tin cy tch bit cc trng hp ung s lng c th gy cht v khng gy cht v (3) thi gian tr hon trc khi tin hnh bin php ny thng cho cc thuc tr c nhm ny c hp thu v phn b vi s lng gy cht, ngay c khi quyt nh lc nhanh chng. Hn na, khi chc nng thn cn bnh thng, kh nng o thi paraquat ca thn hiu qu hn lc mu hp ph 3-10 ln. Thn nhn to c th c tin hnh v suy thn cp nhng c hemodialysis v lc mng bng u khng c hiu qu trong vic lm tng thanh thi cht c. iu tr h tr: Vic truyn dch tinh th sm l quan trng iu tr mt nc, thng l nng, duy tr lu lng nc tiu 12ml/kg/h. Con ng o thi cc thuc tr c nhm bipyridyl ch yu l thn. Lu lng nc tiu y l ti cn thit o thi sm cht c v c th lm chm s xut hin ca suy thn. Tuy nhin bi niu cng bc li khng c vai tr g. xy c th lm nng thm tn thng phi bng vic cung cp thm c cht cho qu trnh hnh thnh cc gc superoxide. C ti liu (Rhodes, 1974) cho thy trn ng vt, cho th xy 10% tt hn 21% (kh phng), cc nghin cu khc trn chut cho thy t l t vong tng ln khi cho chut th xy liu cao. Theo Haley, 1979 v Hayes, 1982, cung cp xy m bo PaO2 mc > 40-50mmHg. Tuy nhin, cho bnh nhn th bng hn hp kh t xy cng khng ngn cn c qu trnh tn thng phi, cha c cc nghin cu c tnh kt lun v quan im ny, do khi bnh nhn b thiu xy vn cn c cung cp xy, ch khng nn cung cp xy mt cch thng quy. Vi ng c paraquat mc gy t vong, vic iu tr vi mc ch gim nh l cch tt nht. iu tr h tr tt, bao gm gim au v chng lo lng l rt quan trng. Bi v iu tr ni khoa li tht bi mt cch ti t trong vic lm cho bnh nhn ng c t trung bnh sang mc nng nn cc nhn vin y t, bnh nhn v gia nh bnh nhn thng hoang mang. Ngh thut ca y hc ng vai tr rt quan trng y chnh l bin php tip cn cc k

kho lo trc mt ci cht ang n gn. Trung thc vi tin lng, khng mt hy vng, nhn mnh nhng iu c th lm c ( v d gim au, cc dch v chm sc v x hi, vai tr ca mc s) l rt c bn trong mt tnh hung kh khn. Ghp phi c p dng nhng khng thnh cng. iu tr c hiu: Mc d ngi ta vn tch cc tm kim nhng cho ti nay vn cha c bin php iu tr c hiu no c ch li. Cha c bng chng lm sng no ng h cho vic s dng thuc gii c trong ng c paraquat. Cc bin php c hiu nghin cu trong ng c paraquat: + Khng cho th xy (ch th xy mt bn phi): Fogt v Zilker (1989) dng bin php ho hc tht ph qun gc mt bn trn chut, lm ngng cung cp xy v xp phi hon ton (qua lm gim ti mu phi), phi cn li c tip tc cung cp xy. Sau tht 2 gi, chut b gy c paraquat vi liu cht. 4-12 ngy sau , cc con chut cht, tn thng m bnh hc ca phi bn b tht khng c c im ca nhim c paraquat. Liu kt qu ny c ngha iu tr ? + Desferrioxamine: nhiu tc gi p dng nguyn l xy ho st v hnh thnh hydroxyl (phn ng Fenton) trn chut, dng desferrioxamine gp st s lm gim vic hnh thnh cc gc t do hydroxyl c, ci thin t l t vong chut b ng c. Tuy nhin kt qu l t l t vong u khng c ci thin. + Cc cht chng xy ho v cc cht iu ho sinh ho khc: lp lun dng cc cht ny da trn hin tng cc cht chng xy ho v cht iu ho sinh ho hot ng ging nh cc cht lm gim v bt gi cc gc t do. (1) Nm 1984, Schvartman th nghim dng hn hp vitamin C v riboflavin trn chut thy ci thin t l sng. (2) Nhiu tc gi khc nghin cu nhng khng thy ch li khi dng vitamin E, niacin, glutathione, GSH, selenium, N-Acetylcystein (nhm sulphydryl), superoxide dismutase ( ph hu cc superoxide d tha), clofibrate (kch thch hot tnh enzym catalase) + Cht c ch nhp paraquat vo phi: trn nghin cu, ngi ta cha thy c li ch ca cc cht polyamine, putrescine, D-propranalol, propranalol trong ng c paraquat. + Cortocoid, cyclophosphamide, cht c ch collagen (L-3,4-dehydroproline): cng khng cho thy c ch li. HNG DN X TR (Trung tm chng c bnh vin Bch Mai) Cn nh l: Ng c paraquat l mt cp cu. Cu sng bnh nhn i hi phi rt khn trng tch cc cho d bnh nhn c triu chng hay cha c triu chng, tp trung ngay vo vic loi b cht c ra khi ngi bnh. Loi b Paraquat ra khi c th Gy nn a. Trong vng 1 gi u mi b ng c. b. Cho ngi bnh ung nhanh 200ml nc sch ri gy nn bng cch ngoy hng. Ra d dy

a. Ch thc hin trong 1gi u sau ng c. b. Mi ln cho vo 200ml nc ly ra 200ml, ri c nh vy ti khi tng s 3-5lt th thi. Ung than hot hay Fullers earth (t st): ngay c nu khng ra d dy c, s lng 30g-100g (1g/kg). Ngay ti hin trng nu khng c than hot th c th pha t hoc t st (t st tt hn) vi nc thnh dng c snh v cho bnh nhn ung ngay. Ra sch tay, da, tm, gi vi nc m v x phng nu ho cht bn, dy ra tc, da, qun, o. Ra mt bng nhiu nc sch ti khi pH tr v bnh thng. Ung nhiu nc v truyn dch t 1,5lit-2,5lit/ngy. Nu huyt p h (<90mmHg) phi dng thuc vn mch: Dopamin, Noradrenalin hay Dobutamin duy tr huyt p. Lc mu hp ph: lm trong vng 6 gi u sau ung, nhanh chng cp cu nh trn, n nh tnh trng bnh nhn v chuyn bnh nhn n c s c iu kin lc mu hp ph. Cc thuc c hiu Phc dng cyclophophamide kt hp corticoid: hin nay c nhiu phc , c th dng mt trong hai phc sau: Phc 1: - Methylprednisolon: 15mg/kg/ngy pha truyn tnh mch vi 500ml NaCl 0,9% trong 2gi/ngy trong 3 ngy lin, phi hp vi: - Cyclophophamide (Endoxan): 15mg/kg/ngy pha truyn tnh mch vi 500ml NaCl 0,9% trong 2gi/ngy trong 2 ngy lin. - Sau thm Dexamethasone 8mg/1ln x 3 ln/ngy, tim tnh mch, trong 14ngy, nu khng c dng tim tnh mch c th dng dng vin ung. Phc 2: - Dexamethasone 10mg/1ln x 3 ln/ngy, trong 7 ngy, tim tnh mch, nu khng c dng tim c th dng dng vin ung. - Cyclophophamide 1,7mg/kg/ln, x 3ln/ngy, tim tnh mch, trong 14 ngy. - Liu cho tr em cha xc nh chnh xc, nhng nn gim xung 1/2 hay 1/3 liu. - Cc thuc h tr: + Mucomyst (N-Acetylcystein) 140mg/kg ung liu u, liu 2 sau 4gi: 70mg/kg, tip tc nh vy 17 liu, nu bnh nhn c vim gan th dng lin tc ti khi ci thin th ngng. Ch kim sot nn khi dng thuc ny. + Vitamin E, Vitamin C, niacin. iu tr triu chng, iu tr h tr: - Ch nn th O2 mi khi c tm mi, u chi, SpO2<90%

- Dn lu kh mng phi nu c trn kh mng phi. - t ni kh qun, th my khi c suy h hp nng. - Thuc bo v nim mc d dy: gastropulgit, phosphalugel, omeprazol. - Gim au, an thn cho bnh nhn. - iu tr triu chng khc nu c. Theo di: o Theo di cc du hiu lm sng, c bit tnh trng h hp, tim mch. o Chc nng gan: SGOT, SGPT, bilirubin, prothrombin. o Chc nng thn: nc tiu, protein niu, ure mu, creatinin mu, in gii mu. o Chp phi: chp ngy t ngy u n vin v theo di x phi n mun (1,2,3 tun sau ng c). o Gii thch cho gia nh v tnh trng nng ca bnh nhn. Xut vin: - Ch khi khng cn triu chng trn lm sng v xt nghim, phi tr li bnh thng sau 2,3 tun.

You might also like