Biến Chứng Liên Quan Đến Thuốc Cản Quang Từ Suy Thận Đến Phản Vệ

Biến chứng liên quan đến thuốc cản quang Từ suy thận đến phản vệ TS.BS Nguyễn Quốc Thái VIỆN TIM MẠCH VIỆT NAM Phân loại thuốc cản quang Thuốc cản quang tia X (Radiographic Contrast Media) Thuốc đối quang từ (MR Contrast Media) Thuốc cản âm (Ultrasound Contrast Media) Phân loại thuốc cản quang tia X Thuốc cản quang Negative (Khí, O2, CO2) Oily Positive Iodine compound Barium GIT Powder Water soluble Thuốc cản quang Iodine Ionic monomeric contrast media (highosmolar contrast media, HOCM), e.g amidotrizoate, iothalamate, ioxithalamate Ionic dimeric contrast media (lowosmolar contrast media, LOCM), e.g ioxaglate Nonionic monomeric contrast media (low osmolar contrast media, LOCM), e.g iohexol, iopentol, ioxitol, iomeprol, ioversol, iopromide, iobitridol, iopamidol Nonionic dimeric contrast media (isoosmolar contrast media, IOCM), e.g iotrolan, iodixanol Contrast Media: Safety issues and ESUR Guidelines 3rd ed.February 2014 Biến chứng không liên quan đến thận Contrast Media: Safety issues and ESUR Guidelines 3rd ed.February 2014 Xử trí biến chứng cấp tính Nổi mày đay Ngừng tiêm thuốc Không cần điều trị phần lớn trường hợp Cho kháng Histamin H1: uống, tiêm bắp Nếu triệu chứng nặng lan rộng cho thuốc đồng vận alpha (co động tĩnh mạch): epinephrin 0.1-0.3 mg tiêm da Phù mặt quản Give O2 6–10 liters/min (via mask) Give alpha agonist (arteriolar and venous constriction): epinephrine SC or IM (1:1,000) 0.1–0.3 ml (= 0.1–0.3 mg) or, especially if hypotension evident, epinephrine (1:10,000) slowly IV –3 ml (= 0.1–0.3 mg) Repeat as needed up to a maximum of mg If not responsive to therapy or if there is obvious acute laryngeal edema, seek appropriate assistance (e.g., cardiopulmonary arrest response team) THA nặng Give O2 6–10 liters/min (via mask) Monitor electrocardiogram, pulse oximeter, blood pressure Give nitroglycerine 0.4-mg tablet, sublingual (may repeat × 3); or, topical 2% ointment, apply 1-inch strip If no response, consider labetalol 20 mg IV, then 20 to 80 mg IV every 10 minutes up to 300 mg Transfer to intensive care unit or emergency department CO GIẬT Give O2 6–10 liters/min (via mask) Consider diazepam (Valium®) mg IV (or more, as appropriate) or midazolam (Versed®) 0.5 to mg IV If longer effect needed, obtain consultation; consider phenytoin (Dilantin®) infusion — 15–18 mg/kg at 50 mg/min Careful monitoring of vital signs required, particularly of pO2because of risk to respiratory depression with benzodiazepine administration Phác đồ xử trí sốc phản vệ Gọi cho đội cấp cứu Đảm bảo đường thở Nâng chân bệnh nhân tụt áp Thở oxy qua mask (6-10l/ph) Adrenaline TB (1:1000): 0.5ml(0.5mg) người lớn, nhắc lại cần thiết Trẻ 6-12 tuổi: TB 0.3ml (0.3mg) Trẻ< tuổi: TB 0.15ml (0.15mg) Truyền TM NaCl sinh lý, Ringer lactat Kháng Histamin H1 TM Contrast Media: Safety issues and ESUR Guidelines 3rd ed.February 2014 Các thuốc phương tiện cấp cứu cần thiết tiến hành dùng thuốc cản quang • • • • • • • • • Oxygen Adrenaline 1:1000 Antihistamine H1 Atropine B2 agonist (Ventolin, Bricanyl): thuốc xịt họng, khí dung Nước muối đẳng trương, Ringer Lactat Thuốc chống co giật (diazepam) Monitor theo dõi HA, NT Dụng cụ đè lưỡi, NKQ Biến chứng muộn • DEFINITION: A late adverse reaction to intravascular iodinebased contrast medium is defined as a reaction which occurs h to week after contrast medium injection • REACTIONS: – Skin reactions similar in type to other drug induced eruptions Maculopapular rashes, erythema, swelling and pruritus are most common Most skin reactions are mild to moderate and self-limiting – A variety of late symptoms (e.g., nausea, vomiting, headache, musculoskeletal pains, fever) have been described following contrast medium, but many are not related to contrast medium Biến chứng muộn RISK FACTORS FOR SKIN REACTIONS: •Previous late contrast medium reaction •Interleukin-2 treatment •Use of nonionic dimers MANAGEMENT: Symptomatic and similar to the management of other drug-induced skin reactions e.g antihistamines, topical steroids and emollients RECOMMENDATIONS: •Patients who have had a previous contrast medium reaction, or who are on interleukin-2 treatment should be advised that a late skin reaction is possible and that they should contact a doctor if they have a problem •Patch and delayed reading intradermal tests may be useful to confirm a late skin reaction to contrast medium and to study cross- reactivity patterns with other agents •To reduce the risk of repeat reaction, use another contrast agent than the agent precipitating the first reaction Avoid agents which have shown cross-reactivity on skin testing Phản ứng muộn Definition: An adverse reaction which usually occurs more than week after contrast medium injection Type of reaction • IODINE-BASED CONTRAST MEDIA Thyrotoxicosis • GADOLINIUM-BASED CONTRAST MEDIA Nephrogenic systemic fibrosis BIẾN CHỨNG THẬN (Renal Adverse Reactions) Biến chứng thận • Definition: Contrast induced nephropathy (CIN) is a condition in which a decrease in renal function occurs within days of the intravascular administration of a CM in the absence of an alternative aetiology An increase in serum creatinine by more than 25% or 44 μmol/l (0.5 mg/dl) indicates CIN Biến chứng thận dùng thuốc can quang Iodine PATIENT-RELATED • eGFR less than 60 ml/min/1.73 m2 before intra-arterial administration • eGFR less than 45 ml/min/1.73 m2 before intravenous administration • In particular in combination with • Diabetic nephropathy • Dehydration • Congestive heart failure (NYHA grade 3-4) and low LVEF • Recent myocardial infarction (< 24 h) • Intra-aortic balloon pump • Peri-procedural hypotension • Low haematocrit level • Age over 70 • Concurrent administration of nephrotoxic drugs • Known or suspected acute renal failure Biến chứng thận dùng thuốc can quang Iodine PROCEDURE-RELATED • Intra-arterial administration of contrast medium • High osmolality agents • Large doses of contrast medium • Multiple contrast medium administrations within a few days Xử trí biến chứng thận dùng thuốc can quang Iodine Elective Examination • Consider an alternative imaging method not using iodinebased contrast media • Discuss the need to stop nephrotoxic drugs with the referring physician • Start volume expansion A suitable protocol is intravenous normal saline, 1.0-1.5 ml/kg/h, for at least h before and after contrast medium An alternative protocol is intravenous sodium bicarbonate (154 mEq/l in dextrose 5% water), ml/kg/h for h before contrast medium and ml/kg/h for h after contrast medium Phòng ngừa biến chứng thận dùng thuốc can quang Iodine Time of examination • AT RISK PATIENTS – Use low or iso-osmolar contrast media – Use the lowest dose of contrast medium consistent with a diagnostic result • PATIENTS NOT AT INCREASED RISK Use the lowest dose of contrast medium consistent with a diagnostic result Biến chứng thận dùng thuốc đối quang từ Gadolinium Examinations • The risk of nephrotoxicity is very low when gadoliniumbased contrast media are used in approved doses RADIOGRAPHIC EXAMINATIONS • Gadolinium-based contrast media should not be used for radiographic examinations in patients with renal impairment • Gadolinium-based contrast media are more nephrotoxic than iodine-based contrast media in equivalent X-ray attenuating doses KẾT LUẬN • Biến chứng liên quan đến thuốc cản quang lâm sàng: gặp đa dạng • Chuẩn bị đầy đủ thuốc phương tiện cấp cứu cần thiết thực phương pháp chẩn đoán thủ thuật có dùng thuốc cản quang