严重地高辛中毒的急诊逐步特异性免疫治疗：一项观察性队列研究

Bilbault Pascal, Oubaassine Rachid, Rahmani Hassene, Lavaux Thomas, Castelain Vincent, Sauder Philippe, Schneider Francis

Division of Emergency and Intensive Care, School of Medicine, Hôpital de Hautepierre, Strasbourg, France.

Eur J Emerg Med. 2009 Jun;16(3):145-9. doi: 10.1097/MEJ.0b013e3283207fce.

OBJECTIVE

To evaluate the efficacy and safety of a step-by-step fixed dose of specific immunotherapy protocol in case of severe digoxin poisoning in an open uncontrolled prospective study.

METHODS

Twenty consecutive patients were admitted because of severe digoxin poisoning. The inclusion criteria were: digoxin overdose and either life-threatening arrhythmia; high-degree atrioventricular block, ventricular arrhythmia, or bradycardia less than 50 bpm and hyperkalaemia (>5.5 mmol/l). A two-step protocol of antidigoxin antibodies treatment was carried out. At admission, every patient received two vials of specific Fab-fragments. If after 1 h following infusion ECG signs regressed, no more treatment was given. If ECG signs did not regress, patients were given two more vials. At inclusion and 6 h after immunotherapy, clinical (cardiac rhythm, ECG records) and biological (serum digoxin concentration, potassium) findings were recorded.

RESULTS

Patients had a median (interquartile range) age of 83 (75-90) years. Four patients had acute poisoning and 16 chronic overdoses. Eleven patients showed ventricular arrhythmia, and five had high-degree atrioventricular block. Seventy percent of the patients needed only the first step. Significant decreases were observed in the number of cardiac dysrhythmia (16 vs. three patients), in the median (interquartile range) of serum digoxin concentration [5 microg/l (3.8-6.2) vs. 0.4 microg/l (0.3-2.2)] and in serum potassium [4.6 mmol/l (4.1-5.5) vs. 3.85 mmol/l (3.7-4.55)] before and after immunotherapy. The digoxin-related mortality was 5%.

CONCLUSION

This protocol of step-by-step digoxin-specific immunotherapy seems to be as effective as the equimolar treatment, and there was significant cost reduction in case of acute poisoning.

目的

在一项开放的非对照前瞻性研究中，评估逐步固定剂量特异性免疫疗法方案治疗严重地高辛中毒的疗效和安全性。

方法

连续收治20例因严重地高辛中毒入院的患者。纳入标准为：地高辛过量且伴有危及生命的心律失常；高度房室传导阻滞、室性心律失常，或心率低于50次/分钟的心动过缓以及高钾血症（>5.5 mmol/L）。实施了两步抗地高辛抗体治疗方案。入院时，每位患者接受两瓶特异性Fab片段。输注后1小时若心电图征象消退，则不再给予进一步治疗。若心电图征象未消退，则再给予患者两瓶。在纳入研究时以及免疫治疗后6小时，记录临床（心律、心电图记录）和生物学（血清地高辛浓度、钾）检查结果。

结果

患者的年龄中位数（四分位间距）为83（75 - 90）岁。4例为急性中毒，16例为慢性过量用药。11例患者出现室性心律失常，5例有高度房室传导阻滞。70%的患者仅需第一步治疗。免疫治疗前后，心律失常患者数量显著减少（16例对3例），血清地高辛浓度中位数（四分位间距）[5 μg/L（3.8 - 6.2）对0.4 μg/L（0.3 - 2.2）]以及血清钾[4.6 mmol/L（4.1 - 5.5）对3.85 mmol/L（3.7 - 4.55）]均显著降低。地高辛相关死亡率为5%。