Perera P M S, Shahmy S, Gawarammana I, Dawson A H
South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka.
Hum Exp Toxicol. 2008 Jun;27(6):513-8. doi: 10.1177/0960327108091861.
There is a wide variation and lack of evidence in current recommendations for atropine dosing schedules leading to subsequent variation in clinical practice. Therefore, we sought to examine the safety and effectiveness of a titrated vs. ad hoc atropine treatment regimen in a cohort of patients with acute cholinesterase inhibitor pesticide poisoning. A prospective cohort study was conducted in three district secondary referral hospitals in Sri Lanka using a structured data collection form that collected details of clinical symptoms and outcomes of cholinesterase inhibitor pesticide poisoning, atropine doses, and signs of atropinization. We compared two hospitals that used a titrated dosing protocol based on a structured monitoring sheet for atropine infusion with another hospital using an ad hoc regime. During the study, 272 symptomatic patients with anticholinesterase poisoning requiring atropine were admitted to the three hospitals. Outcomes of death and ventilation were analyzed for all patients, 226 patients were prospectively assessed for atropine toxicity. At baseline, patients in the titrated dose cohort had clinical signs consistent with greater toxicity. This in part may be due to ingestion of more toxic organophosphates. They received less pralidoxime and atropine, and were less likely to develop features of atropine toxicity, such as delirium (1% vs. 17%), hallucinations (1% vs. 35%), or either (1% vs. 35%) and need for patient restraint (3% vs. 48%) compared with the ad hoc dose regime. After adjusting for the pesticides ingested, there was no difference in mortality and ventilatory rates between protocols. Ad hoc high dose atropine regimens are associated with more frequent atropine toxicity without any obvious improvement in patient outcome compared with doses titrated to clinical effect. Atropine doses should be titrated against response and toxicity. Further education and the use of a structured monitoring sheet may assist in more appropriate atropine use in anticholinesterase pesticide poisoning.
目前关于阿托品给药方案的建议存在很大差异且缺乏证据，这导致了临床实践中的后续差异。因此，我们试图在一组急性胆碱酯酶抑制剂农药中毒患者中研究滴定法与临时使用阿托品治疗方案的安全性和有效性。在斯里兰卡的三家地区二级转诊医院进行了一项前瞻性队列研究，使用结构化数据收集表收集胆碱酯酶抑制剂农药中毒的临床症状和结果、阿托品剂量以及阿托品化体征的详细信息。我们将两家使用基于阿托品输注结构化监测表的滴定给药方案的医院与另一家使用临时方案的医院进行了比较。在研究期间，三家医院共收治了272例需要阿托品治疗的有症状抗胆碱酯酶中毒患者。分析了所有患者的死亡和通气结局，对226例患者进行了阿托品毒性的前瞻性评估。在基线时，滴定剂量队列中的患者临床体征表明毒性更大。这部分可能是由于摄入了毒性更强的有机磷酸酯。与临时剂量方案相比，他们接受的解磷定和阿托品较少，出现阿托品毒性特征（如谵妄，1% 对17%；幻觉，1% 对35%；或两者皆有，1% 对35%）以及需要约束患者（3% 对48%）的可能性较小。在调整摄入的农药因素后，两种方案之间的死亡率和通气率没有差异。与根据临床效果滴定剂量相比，临时高剂量阿托品方案与更频繁的阿托品毒性相关，而患者结局没有明显改善。阿托品剂量应根据反应和毒性进行滴定。进一步的教育以及使用结构化监测表可能有助于在抗胆碱酯酶农药中毒中更恰当地使用阿托品。
