Yuav tsum zam qhov sib piv-txhim kho CT hauv CKD Theem 4 cov neeg mob?
Jan 04, 2023
Ntshai txog qhov sib txawv ntawm qhov mob raum raug mob tau cuam tshuam rau kev txiav txim siab kho mob rau ntau tshaj li ib nrab xyoo pua. Mob raum raug mob tshwm sim los ntawm qhov sib piv nruab nrab feem ntau suav hais tias yog ib qho tseem ceeb ua rau mob raum mob hauv tsev kho mob. Yuav kho lub raum puas tshwm sim los ntawm qhov sib piv nruab nrab yuav tsum tau tshawb nrhiav ntxiv.
Nyem rau Herb Cistanche txiaj ntsig rau kab mob raum
Thaum Lub Kaum Ib Hlis 2022, phau ntawv xov xwm thoob ntiaj teb tso cai "New England Journal of Medicine" (NEJM) tau tshaj tawm cov ntaub ntawv paub daws teeb meem: Ib rooj plaub ntawm kev xav tias pulmonary embolism nyob rau hauv tus neeg mob uas muaj theem 4 mob raum (CKD) yuav tsum tau txais kev sib piv tus neeg sawv cev-txhim kho CT kuaj qhov chaw. tsis ntseeg, Caw cov npe loj hauv kev lag luam los sib tham. Cov kws txawj muab tswv yim zoo li cas? Cia peb saib!
Cov ntaub ntawv tseem ceeb:
Tus neeg mob yog txiv neej, 65 xyoo.
Tus Thawj Saib Xyuas Kev Tsis Txaus Siab: 6 teev dhau los, nws tau nthuav tawm mus rau lub tuam tsev kho mob xwm txheej ceev nrog qhov tshwm sim sai sai ntawm kev ua tsis taus pa, mob hauv siab, thiab kiv taub hau me ntsis.
Keeb Kwm Ntawm Kev Mob Tam Sim No: Dyspnea nrog lub hauv siab tsis xis nyob thiab kiv taub hau me ntsis.
History: type 2 diabetes mellitus, Ⅱ degree obesity BMI>35, kab mob plawv, kab mob raum ntev eGFR 28mL/(min·1.73m2).
Kev tshuaj xyuas lub cev: lub cev kub yog qhov qub, ntshav siab yog 135/88mmHg, lub plawv dhia yog 109 neeg ntaus / min, tus nqi ua pa yog 22 neeg ntaus / min, oxygen saturation yog 87 feem pua, thiab tsis muaj edema nyob rau hauv qis extremities.
Kev kuaj xyuas:
Lub electrocardiogram pom qhov sinus tachycardia yam tsis muaj ST ntu thiab T yoj hloov.
Qhov ntsuas D-dimer yog 724 ng / mL (kev siv ntau yam<650 ng/mL).
High-rhiab heev troponin kuv tsis tau kuaj pom.
Yog tias koj yog tus kws kho mob xwm txheej ceev pom tus neeg mob tam sim no, koj feem ntau xav txog CT, zoo dua txhim kho CT nrog qhov sib txawv, los txiav txim seb puas muaj pulmonary embolism. Tab sis koj tab tom ntsib tus neeg mob CKD theem 4, muaj ob txoj kev kho mob hauv qab no, koj yuav xaiv tus twg?
Option 1: Contrast-enhanced CT yog pom zoo
Cov ntaub ntawv no piav qhia txog qhov xwm txheej uas cov kws kho mob hauv chav kho mob xwm txheej ceev tau paub zoo. Tus neeg mob muaj cov tsos mob thiab cov tsos mob txaus ntshai, thiab kev tshuaj xyuas CT nrog tus neeg sawv cev sib txawv tuaj yeem paub meej qhov kev kuaj mob sai. Txawm li cas los xij, tus neeg mob nyob hauv CKD theem 4. Tom qab siv cov tshuaj sib txawv, lub raum tsis ua haujlwm yuav ua rau muaj kev pheej hmoo ntawm kev xaus, yuav ua li cas nrog qhov no?
Tus neeg mob no xav tau kev kuaj mob ntxiv ntawm pulmonary embolism. (1) Kev kuaj lub ntsws / qhov cua tuaj yeem siv los ua lwm txoj hauv kev sib txawv ntawm tus neeg saib xyuas-txhim kho CT, tab sis qhov kev ntsuam xyuas no muaj ntau qhov kev txwv: tsis yog txhua lub tsev kho mob tuaj yeem ua tiav qhov kev ntsuam xyuas ntawm cov nqi hluav taws xob tsawg hauv cov neeg mob uas muaj qhov txawv txav hauv siab x-rays; Txawm tias nyob rau hauv cov xwm txheej zoo, cov duab perfusion / qhov cua tuaj yeem txhais tsis sib xws ntawm cov neeg nyeem; Txhim kho CT kuaj raws li kev kuaj mob ntawm lwm yam kab mob. (2) Ultrasound kuaj ntawm ob sab qis sab hauv cov hlab ntsha tuaj yeem siv los kuaj xyuas cov leeg sib sib zog nqus thromboembolism kom cov tshuaj tiv thaiv coagulant tuaj yeem pib thaum tsis muaj pov thawj tseeb ntawm pulmonary embolism. Txawm li cas los xij, tus kws kho mob hluav taws xob uas tuaj yeem txhais cov duab ultrasound thiab tus kws kho mob uas tau kawm hauv qhov taw qhia ntawm kev saib xyuas ultrasound tsis tas yuav tshwm sim ib txhij. Tsis tas li ntawd, tus neeg mob no tsis muaj cov tsos mob ntawm kev sib sib zog nqus venous thromboembolism.
Yog tias cov txiaj ntsig ntawm ultrasound tsis zoo, kev siv txoj kev kuaj xyuas no yuav ncua sij hawm ntawm kev kuaj mob thiab kev kho mob rau tus neeg mob no uas muaj cov cim qhia pom tseeb ntawm cov kab mob cardiopulmonary. (3) Kev kho tus kheej nrog cov kab mob anticoagulants kuj yog ib qho kev xaiv, tab sis muaj kev pheej hmoo los ntshav. 2 feem pua ntawm cov neeg mob uas muaj venous thromboembolism tuaj yeem tshwm sim los ntshav loj thaum pib kho, uas tsis tsim nyog rau cov neeg mob uas tsis tau kuaj pom tus kab mob txaus ntshai. (4) Nws tsis tsim nyog tsis muab kev kuaj xyuas ntxiv. Kev ncua kev kuaj mob thiab kev kho mob ntawm tus mob pulmonary embolism yuav ua rau muaj kev pheej hmoo ntawm kev tuag luv luv thiab muaj teeb meem ntev rau cov neeg mob.
Ntau xyoo dhau los, ntau qhov kev soj ntsuam loj soj ntsuam cov ntaub ntawv los ntawm ntau lab tus neeg mob tau pom tias qhov kev pheej hmoo ntawm mob raum raug mob los ntawm cov kab mob sib txawv hauv cov hlab ntsha yog qis dua li yav dhau los xav. Lub 2020 American College of Radiology thiab National Kidney Foundation tau tshuaj xyuas cov pov thawj muaj thiab luam tawm cov lus qhia tshiab ntawm kev siv cov tshuaj iodine sib txawv hauv cov neeg mob CKD. Nws tau tshaj tawm tias thaum eGFR loj dua lossis sib npaug li 45 mL / (min·1.73m2), qhov kev pheej hmoo ntawm qhov sib txawv nruab nrab ntawm lub raum raug mob yog ze rau xoom, thiab thaum eGFR yog 30-44mL/ (min·1.73m2), qhov kev pheej hmoo ntawm qhov sib txawv nruab nrab ntawm lub raum raug mob yog ze rau xoom. Qhov kev pheej hmoo ntawm kev raug mob tsuas yog siab dua me ntsis (tsawg dua lossis sib npaug li 2 feem pua).
Rau cov neeg mob lub raum mob hnyav (eGFR<30mL/[min·1.73m]2), the evidence for this is less clear, as no studies have adequately and reliably assessed the use of contrast media in this population. risk. However, a meta-analysis of relevant research data (including more than 3500 patients with eGFR <30mL/[min·1.73m2]) showed that there was no independent association between acute kidney injury and the use of contrast media. The American College of Radiology and the National Kidney Foundation acknowledge that in patients with CKD stages 4 or 5, there may be an increased risk of acute kidney injury following the administration of contrast media, but advise against evaluating or treating a potentially life-threatening diagnosis based solely on renal function.
Rau tus neeg mob tau nthuav tawm hauv qhov xwm txheej no, qhov kev pheej hmoo ntawm kev kuaj tsis tau lossis ncua sij hawm ntawm kev mob ntsws pulmonary embolism deb tshaj qhov kev pheej hmoo ntawm mob raum mob uas tuaj yeem tshwm sim los ntawm kev txhim kho CT. Raws li cov ntaub ntawv pov thawj thiab cov lus pom zoo pom zoo ntawm American College of Radiology thiab National Kidney Foundation, Kuv pom zoo kom muaj qhov sib txawv-txhim kho CT nrog rau kev tsom mus rau thaj chaw paub tias cuam tshuam rau lub raum cov txiaj ntsig thiab kev ntsuas rau lub raum tsis zoo: hemodynamic stabilization Tsis txhob siv tshuaj nephrotoxic thiab tsis tsim nyog. kho cov kab mob kom sai.
Kev xaiv 2: Kev pom zoo kom tsis txhob muaj qhov sib txawv-txhim kho CT
Tus neeg mob tau piav qhia nyob rau hauv rooj plaub tau nthuav tawm cov cim qhia thiab cov tsos mob uas qhia tias muaj kev pheej hmoo ntawm pulmonary embolism raws li Wells cov txheej txheem, ib qho cuab yeej uas pab cov kws kho mob soj ntsuam qhov tshwm sim ntawm pulmonary embolism. Pulmonary embolism yog qhov tshwm sim, tuaj yeem ua rau tuag taus, thiab yuav tsum tau kuaj cov duab rau kev kuaj mob. Hauv cov neeg mob uas tsis muaj contraindications rau iodinated contrast media, qhov kev ntsuam xyuas tsim nyog tshaj plaws yog hauv siab sib piv-enhanced CT angiography, nrog rau American College of Radiology txaus qhab nia ntawm 9 (ntawm qhov ntsuas ntawm 1 txog 9.9), thiab CT angiography tuaj yeem kuaj pom Pulmonary embolism vim yog. ntawm nws siab rhiab heev thiab tshwj xeeb.
Rau cov neeg mob uas muaj contraindications rau iodine contrast media, xaiv kev tshuaj ntsuam muaj xws li ib tug technetium-99m ventilation-perfusion scan, lub hauv siab radiography, thiab xim Doppler ultrasonography ntawm cov leeg sab sab. Txawm hais tias cov kev ntsuam xyuas no tsis raug raws li CT angiography, lawv tuaj yeem muab cov ntaub ntawv tseem ceeb rau kev soj ntsuam kev pheej hmoo thiab kev kuaj mob, suav tias yog "feem ntau tsim nyog" los ntawm American College of Radiology thiab tsis tas yuav muaj cov tshuaj iodinated sib piv. Thaum txiav txim siab qhov kev sim ua, tus kws kho mob yuav tsum txiav txim siab seb puas muaj iodinated contrast media yog contraindicated.
Dab tsi yog qhov kev pheej hmoo ntawm qhov sib txawv ntawm lub raum raug mob rau cov neeg mob uas muaj CKD theem 4 lossis 5 uas tau txais kev sib piv-txhim kho CT? Qhov kev pheej hmoo tsis paub, tab sis kev kwv yees los ntawm American College of Radiology thiab National Kidney Foundation muaj li ntawm 0 mus rau 17 feem pua. Cov ntaub ntawv keeb kwm ntawm qhov sib txawv-vim lub raum raug mob raug mob vim tsis muaj kev tswj xyuas tsim nyog thiab ua rau muaj kev cuam tshuam ntawm qhov sib txawv ntawm lub raum raug mob nrog qhov sib txawv ntawm lub raum raug mob; cov kev tshawb fawb tau ua nyob rau kaum xyoo dhau los tau pab qhia meej txog qhov muaj feem pheej hmoo tiag tiag, tab sis kuj muaj kev txwv.
Vim muaj kev xav txog kev coj ncaj ncees thiab txwv cov qauv loj hauv cov neeg muaj kev pheej hmoo siab, tam sim no tsis muaj kev sim randomized ncaj qha los ntsuas qhov kev pheej hmoo ntawm qhov sib txawv ntawm lub raum raug mob rau cov neeg mob uas muaj CKD theem 4 lossis 5. Hauv qhov sib piv, ntau qhov kev tshawb fawb loj rov qab uas muaj ntau pua tus. Cov neeg mob uas muaj kev pheej hmoo siab dhau los ua qhov sib txawv-txhim kho CT, suav nrog cov hauv chaw kho mob xwm txheej ceev, nrog rau kev tshuaj ntsuam xyuas rau cov qhab nia zoo sib xws lossis lwm txoj hauv kev tswj hwm qib siab, tau tsim cov txiaj ntsig tsis sib haum. xaus. Qee qhov kev tshawb fawb tau pom tias muaj kev pheej hmoo ntawm mob raum raug mob (nrog lossis tsis muaj kev lim ntshav) nrog cov neeg ua haujlwm sib txawv hauv cov neeg mob uas muaj CKD theem 4 lossis 5, thaum lwm tus tsis muaj.
Raws li cov txiaj ntsig zoo li no, American College of Radiology thiab National Kidney Foundation tau xaus lus tias qhov kev pheej hmoo ntawm qhov sib txawv ntawm lub raum raug mob rau cov neeg mob CKD theem 4 yog qhov tsis meej tab sis tsis muaj qhov tsis txaus ntseeg. Qhov kev pheej hmoo yog qhov tseeb dua rau cov neeg mob uas muaj eGFR ntawm 30 txog 44 mL/(min 1.73 m2) (kev pheej hmoo 0 rau 2 feem pua) lossis Ntau dua lossis sib npaug li 45 mL/(min 1.73 m2 ) (risk txog 0). Nyob rau hauv cov ntaub ntawv no, tus neeg mob tus eGFR yog<30 mL/(min·1.73 m2), at which level the risk of contrast-induced acute kidney injury is less certain.
Tsis tas li ntawd, American College of Radiology thiab National Kidney Foundation tau taw qhia tias rau cov neeg mob nrog CKD theem 4, qhov sib piv-txhim kho CT kev kuaj mob kuj yog contraindicated. Yog li ntawd, lwm txoj kev kuaj mob tau lees paub.
Yog xav paub ntxiv:ali.ma@wecistanche.com
