尿液鹼化原理是毒物從經由腎臟排除, 毒物為弱酸性的情況, 分佈於細胞外液並且protein binding不強. (像NSAID與protein binding強就無用)
l 中重度salicylate毒性未達hemodialysis程度
l Phenobarbital (多劑量activated charcoal較優)[1].
l Chlorophenoxy herbicides
(2-4-dichlorophenoxyacetic acid and mecoprop): 須高尿流量 600 mL/h 較有效 [2, 3], forced
diuresis 也是有幫忙的[4]
l Chlorpropamide: supportive care/IV
dextrose normally sufficient.
l Toxicities of High-Dose Methotrexate [5]
尿液鹼化禁忌症
l 本來患者狀況fluid就overload
l Renal impairment: CKD, uremia.
l 本來血鉀就很低(Uncorrected
hypokalemia), 避免低血鉀引發VT [6] 最好keep 血鉀在4—4.5 mEq/L [7]
尿液鹼化併發症:
l Hypokalemia.
l Volume overload.
l 鹼血症(Alkalemia);
l 輕度Hypocalcemia
尿液鹼化監測
REFERENCES
尿液鹼化做法:
NaHCO3- 1 amp in N/S 1 BT run 125 ml, 有uremia, CHF, CKD 需調整滴速 [8]
1–2 mEq/kg IV bolus followed by 2 mEq/kg per h IV infusion
Sodium bicarbonate 4 amps in D5W 500ml run 250 mL/hr. (可以加20 mEq of
potassium chloride避免低血鉀)
Keep urine output of 1 to 2 mL/kg per hour
urine pH 每 15 to 30分測尿的pH 保持7.5 to 8.5.
尿液鹼化曾用於Brazil 與 Iran的organophosphate
poisoning 但並無有效實證。[9], 另抗發炎製劑Diflunisal和NSAID 也是無效 [10].
尿液酸化
urinary
acidification 可以增加弱鹼的移除(包括 amphetamines和phencyclidine), 但產生的相關危險性(例如
rhabdomyolysis) 往往超過尿液酸化原本的好處.
尿液酸化對MAOI的移除是無效的[4]
REFERENCES
[1]: Lindberg MC, Cunningham A, Lindberg NH. Acute phenobarbital
intoxication. South Med J. 1992;85(8):803–807.
doi:10.1097/00007611-199208000-00004
[2]: Bradberry SM, Proudfoot AT, Vale JA. Poisoning due to
chlorophenoxy herbicides. Toxicol Rev. 2004;23(2):65–73.
doi:10.2165/00139709-200423020-00001
[3]: Roberts DM, Buckley NA. Urinary alkalinisation for acute
chlorophenoxy herbicide poisoning. Cochrane Database Syst Rev.
2007;(1):CD005488. Published 2007 Jan 24. doi: 10.1002/14651858.CD005488.pub2
[4]: Tintinalli’s Emergency Medicine, 8th ed. P.1227
[5]: Howard SC, McCormick J, Pui CH, Buddington RK, Harvey RD.
Preventing and Managing Toxicities of High-Dose Methotrexate. Oncologist.
2016;21(12):1471–1482. doi:10.1634/theoncologist.2015-0164
[6] Tsai IH, Su YJ. Thyrotoxic periodic paralysis with ventricular
tachycardia. J Electrocardiol. 2019; 54:93–95. doi: 10.1016/j.jelectrocard.2019.04.001
[7] Tintinalli’s Emergency Medicine, 8th ed. P.1268.
[8]. Table 176-2. Tintinalli’s Emergency Medicine, 8th
ed. P.1208 -1212.
[9]. Tintinalli’s Emergency Medicine, 8th ed. P.1320.
[10]: Balali-Mood M, Prescott LF. Failure of alkaline diuresis to
enhance diflunisal elimination. Br J Clin Pharmacol. 1980;10(2):163–165.
doi:10.1111/j.1365-2125. 1980.tb01734.x
-- edited 11th Jan, 2020 Yu-Jang Su.