泛影葡胺致迟发性过敏性休克救治体会和预防

泛影葡胺是一种水溶性、高渗离子型有机碘造影剂，使用前必须做碘过敏试验。近年来，碘过敏试验阴性，但造影仍发生不良反应的报道增多。在临床上，由药物引起的过敏性休克种类较多，其中急发性过敏性休克较常见，而迟发性过敏性休克则罕见或少见。一旦发生，难以防治。我院从1986～2005年间共进行静脉肾盂造影、血管造影等各种造影1000例，其中因泛影葡胺致迟发性过敏性休克9例，占0．9％。男6例，女3例。现将在我院对泛影葡胺致迟发性过敏性休克的临床类型、临床表现、发生机制及防治措施等予以回顾和综述如下。     

离子型造影剂过敏试验对非离子型造影剂造影不良反应的预测价值

目的探讨离子型造影剂（碘）过敏试验对非离子型造影剂造影不良反应的预测价值。方法对2006例行非离子型造影剂造影检查的患者使用30%泛影葡胺试敏剂进行过敏试验,阴性者进行造影,阳性者待过敏症状消失后,于造影前使用非离子型造影剂1ml静脉注射,观察15min无反应后再全量注射进行造影,观察造影后患者不良反应发生情况。结果2006例患者中碘过敏试验阴性者2001例（99.75%）,阳性者5例（0.25%）。5例阳性患者行非离子型造影剂过敏试验阴性,注射全量造影后未发生不良反应;2001例阴性者造影过程中及造影后出现不良反应39例（1.95%）。结论离子型造影剂过敏试验对非离子型造影剂造影不良反应无预测价值。     

静脉肾盂造影76%泛影葡胺注射速度与不良反应关系研究

目的探讨静脉肾盂造影76%泛影葡胺注射速度与不良反应发生的关系,以降低不良反应发生率。方法按预约检查顺序将1280例静脉肾盂造影患者随机分为六组,注射泵控制76%泛影葡胺注射速度,1组214例为4ml/min、2组214例为6ml/min、3组213例为8ml/min、4组213例为10ml/min,5组213例、6组213例患者注射速度同3组及4组,但在76%泛影葡胺注射液中加入地塞米松注射液10mg。结果 1280例患者中,发生高渗透压反应404例(31.56%),发生过敏反应25例(1.95%),高渗反应发生率显著高于过敏反应发生率(P0.01)。高渗反应发生率六组比较,差异有统计学意义(P0.01),其中1组、2组显著低于其他四组,3组、5组分别显著低于4组、6组(均P0.003)。一般过敏反应发生率各组比较,差异有统计学意义(P0.01)。结论静脉肾盂造影时的不良反应主要为高渗反应,控制静脉注射76%泛影葡胺的速度,可降低不良反应发生率。     

离子型造影剂过敏试验对非离子型造影剂造影不良反应的预测价值

目的 探讨离子型造影剂(碘)过敏试验对非离子型造影剂造影不良反应的预测价值.方法 对2 006例行非离子型造影剂造影检查的患者使用30%泛影葡胺试敏剂进行过敏试验,阴性者进行造影,阳性者待过敏症状消失后,于造影前使用非离子型造影剂1 ml静脉注射,观察15 min无反应后再全量注射进行造影,观察造影后患者不良反应发生情况.结果 2 006例患者中碘过敏试验阴性者2 001例(99.75%),阳性者5例(0.25%).5例阳性患者行非离子型造影剂过敏试验阴性,注射全量造影后未发生不良反应;2 001例阴性者造影过程中及造影后出现不良反应39例(1.95%).结论离子型造影剂过敏试验对非离子型造影剂造影不良反应无预测价值.     

静脉肾盂造影76％泛影葡胺注射速度与不良反应关系研究

目的探讨静脉肾盂造影76％泛影葡胺注射速度与不良反应发生的关系,以降低不良反应发生率。方法按预约检查顺序将1280例静脉肾盂造影患者随机分为六组,注射泵控制76％泛影葡胺注射速度,1组214倒为4ml／min、2组214例为6ml／min、3组213例为8ml／min、4组213例为10ml／min,5组213例、6组213例患者注射速度同3组及4组,但在76％泛影葡胺注射液中加入地塞米松注射液10mg。结果1280例患者中,发生高渗透压反应404例（31．56％）,发生过敏反应25侧（1．95％）,高渗反应发生率显著高于过敏反应发生率（P〈0．01）。高渗反应发生率六组比较,差异有统计学意义（P〈0．01）,其中1组、2组显著低于其他四组,3组、5组分别显著低于4组、6组（均P〈0．003）。一般过敏反应发生率各组比较,差异有统计学意义（P〈0．01）。结论静脉肾盂造影时的不良反应主要为高渗反应,控制静脉注射76％泛影葡胺的速度,可降低不良反应发生率。     

早期鼻饲泛影葡胺对粘连性肠梗阻诊治价值的临床研究

目的 探讨早期鼻饲泛影葡胺对粘连性肠梗阻的诊断及治疗效果.方法 对95例临床及x线检查确诊之粘连性肠梗阻患者被为分研究组与对照组.48例经胃管注入76%复方泛影葡胺80 ml为研究组,同时设无需胃管注人造影剂为空白对照组47例进行比较.结果 研究组中40例造影剂在6～24 h内到达结肠而 给予保守治疗,平均症状缓解时间为16±2.5 h,1～5 d(平均2.8 d)后症状消失;另8例见造影剂未进入结肠且症状体征加重选择及时剖腹手术治疗.对照组手术治疗16例,7例出现绞窄性肠梗阻.中转手术率及绞窄性肠梗阻发生率两组比较(16.67% vs 34.04%;2.08%v8 14.89%)均有显著性差异(P<0.05).结论 复方泛影葡胺应用于胃肠道造影对明确粘连性肠梗阻的梗阻部位及合理选择手术时机有很好的指导作用,早期鼻饲泛影葡胺有助于肠梗阻的缓解.     

应用碘油造影诊断小肠梗阻的可行性分析

目的 研究应用碘油造影诊断小肠梗阻的可行性以及手术时机的选择。方法 回顾性研究2004年1月至2008年6月湖南郴州市第一人民医院胃肠外科231例小肠梗阻临床资料,分为碘油组（163例）和泛影葡胺组（68例）。病人经胃管注入造影剂行消化道造影,腹部X线动态观察观察碘油造影剂24h内是否进入结肠与病人最终是否采取手术治疗的一致性,并对此一致性做Kappa分析,同时分别观察两组6、12、24、36h各时间点的显影情况。结果 碘油组：Kappa值为0.946,6h、12h、24h、36h碘油组显影率分别为100%、98.8%、93.9%、80.7%,泛影葡胺组为100%、95.6%、85.2%、34.0%。结论 碘油造影是泛影葡胺外另一种可靠的诊断小肠梗阻的手段,对手术时机选择具有重要的指导意义。     

排泄性尿路造影致过敏性休克一例

患者男,27岁。因输尿管结石,行静脉肾盂造影。造影前按常规行过敏试验,先点眼,后用30%泛影葡胺1ml静脉注入试验,均阴性。然后将60%泛影葡胺20ml缓慢注入静脉,5分钟后,患者出现颜面潮红、打嚏喷、咳嗽,解开腹部压迫带,停止拍照。立即肌注苯海拉明25mg,症状未见缓解,出现频咳、周身瘗痒、头昏、恶心呕吐、视物不清、神志恍忽,呼吸困难,口唇发绀、四肢冷凉、脉搏细弱,血压90/70,双肺喘鸣音。     

泛影葡胺和碘曲仑对糖尿病大鼠肾毒性的比较

目的:观察高渗离子造影剂76%泛影葡胺和等渗非离子造影剂碘曲仑对糖尿病大鼠肾毒性的不同.方法:建立单侧肾切除糖尿病大鼠模型,模型建立8周后,禁水24 h,尾静脉分别一次性注射76%泛影葡胺和碘曲仑[10 ml/kg,3 gI(iodine)/10 ml].72 h后按不同要求留取血及组织标本,测定大鼠血肌酐和尿素氮,放射免疫法测定血及肾组织中ET的浓度,硝酸还原酶法测定NO水平,同时观察肾组织形态变化.结果:糖尿病大鼠血肌酐、尿素氮与正常组相比均明显增加(P<0.01),HOCM组血肌酐、尿素氮较DM组进一步升高(P<0.05),且HOCM组与DM组相比,ET水平升高、NO含量进一步减少(P<0.05),ET/NO比值显著增高(P<0.01),而IOCM组各项指标均较DM组变化不明显;形态学观察结果亦提示76%泛影葡胺引起的肾脏改变较明显.结论:高渗离子造影剂泛影葡胺可以引起糖尿病大鼠肾功能明显降低,而非离子等渗造影剂碘曲仑引起肾功能下降轻微,这可能与泛影葡胺导致了糖尿病大鼠肾组织ET/NO的严重失衡有关.碘曲仑在糖尿病大鼠较少引起造影剂肾病.     

76%泛影葡胺肾盂灌注联合体外冲击波治疗乳糜尿6例报告

目的探讨泛影葡胺肾盂灌注联合体外冲击波（ESW）治疗乳糜尿的有效性及安全性。方法 2007年6月～2011年12月,6例确诊为乳糜尿,均无确诊血丝虫病,其中1例有丝虫病区生活史,2例有左侧腹股沟大隐静脉淋巴吻合手术史。膀胱镜下确定乳糜尿患侧,逆行插入F5输尿管外支架管后采用76%泛影葡胺经导管低压肾盂灌注,了解造影剂有无反流和肾窦位置后,行ESW冲击造影剂外渗部位通道。结果 6例均见到肾盂、肾盏淋巴反流通道,ESW一次治疗成功,术中、术后未出现感染、包膜下血肿等。随访3～37个月,平均18个月,均无复发,无高血压等远期并发症出现。结论泛影葡胺肾盂灌注联合ESW治疗乳糜尿的效果好,安全,患者依从性良好,可作为该病的常规治疗手段。     

不同温度对比剂与CT血管造影不良反应间的关系研究

【摘要】〓目的〓探讨注射不同温度的碘对比剂进行CT血管造影时受检者不良反应(ADR)的发生。方法〓将3200例进行多层螺旋CT血管造影的受检者随机分为常温组(n=1520)和加温组(n=1680),常温组与加温组分别在室温下(18℃~22℃)与将对比剂放入恒温箱加热至37℃后进行血管造影,观察两组受检者的外渗和过敏样反应的发生率。结果〓静脉注射碘普罗胺(优维显370)进行血管造影时,加温组的外渗和过敏样反应的发生率明显低于常温组。结论〓加热碘对比剂能明显降低不良反应的发生,值得大力推广应用。     

Comparative study on nephrotoxicity of ionic and non-ionic contrast agents for drip infused urography]

The effects on renal function of an ionic and hyperosmolaric contrast agent (diatrizoate) and a non-ionic and slightly hypertonic agent (iohexol) for drip infused urography were compared on 60 patients with normal renal function. Urine samples were collected before and 30 minutes after drip infusion of contrast agent, and analyzed for albumin (ALB), gamma-glutamyl transpeptidase (gamma-GTP), N-acetyl-beta-glucosaminidase (NAG), beta 2 microglobulin (beta 2MG) and creatinine (CRE). The urinary excretion of proteins and enzymes was compared with urinary CRE. gamma-GTP, NAG and beta 2MG increased significantly after infusion of diatrizoate. gamma-GTP and beta 2MG increased significantly after infusion of iohexol. Excretion of ALB, gamma-GTP, NAG and beta 2MG was significantly higher after infusion of diatrizoate than after iohexol. The urinary concentration of CRE was significantly lower after infusion of diatrizoate than after iohexol. The degree of renal damage after urography was no related to the appearance of allergy to the contrast agent or age of patient. Therefore, the non-ionic and slightly hyperosmolaric iohexol may be less toxic to the kidneys than the ionic and hypertonic diatrizoate. This nephrotoxicity after drip infused urography is thought to be related mainly to the osmolarity of contrast agent.     

高渗和低渗造影剂对人肾小管上皮细胞的毒性作用

目的 比较高渗造影剂（HOCM，泛影葡胺）和低渗造影剂（LOCM，欧乃派克）对人肾小管上皮细胞的毒性，探讨Bax／Bcl-2，半胱氨酸天冬氨酸蛋白酶（caspase）-3在造影剂诱导肾小管上皮细胞凋亡中的作用。方法 以HKC细胞株为研究对象，实验分为7组：HOCM1组（111mgI／ml），HOCM2组（74mgI／m1），LOCMl组（111mgI／m1），LOCM2组（74mgI／ml），甘露醇高渗对照组，甘露醇低渗对照组，培养基对照组。采用四甲基偶氮唑蓝（MTT）试验和乳酸脱氢酶（LDH）检测造影剂对体外培养HKC细胞的毒性作用。采用Hoechst染色、TUNEL染色、DNA琼脂糖凝胶电泳、电镜和流式细胞仪DNA分析方法观察造影剂对HKC细胞凋亡的作用。采用Westem印迹方法检测Bax和Bcl-2蛋白含量的变化。采用荧光比色法检测caspase-3活性。结果 HOCM和LOCM组培养液中LDH水平较对照组显著增高（P〈0．05），细胞活力较对照组显著降低（P〈0．05），且与渗透浓度，作用时间及碘离子浓度有关。HOCM可诱导肾小管上皮细胞凋亡，且明显高于甘露醇高渗对照（P〈0．05）。LOCM在本实验剂量不能诱导肾小管上皮细胞凋亡。HOCM在诱导HKC细胞凋亡时伴随有Bax、Bcl-2表达的上调，caspase-3活性升高。结论 HOCM和LOCM对肾小管上皮细胞均有毒性作用，LOCM的毒性作用明显小于HOCM。HOCM可诱导人肾小管上皮细胞凋亡且与高渗及碘离子浓度有关。Bax／Bcl-2、caspase-3可能参与了造影剂诱导人肾小管上皮细胞凋亡的调控。     

Digital subtraction angiography for evaluating patients with renal carcinoma

Intravenous digital subtraction angiography has been performed on 39 patients with renal carcinoma. In 19 patients (group 1) imaging of the renal arteries was done following injection of 40 cc intravenous contrast medium through an antecubital vein. In 20 patients (group 2) 40 cc intravenous contrast medium were injected through a femoral vein and digital subtraction imaging of the inferior vena cava was obtained. In 12 of these patients the renal arteries also were visualized from the same injection of contrast medium. Intra-arterial digital subtraction angiography of the renal arteries also was done in 5 patients in group 2. Intravenous digital subtraction angiography satisfactorily demonstrated main renal arterial anatomy in 29 of 35 patients (83 per cent) over-all but failed to delineate the renal mass in most cases. Excellent visualization of the inferior vena cava was obtained in all 20 patients in group 2. Intraarterial digital subtraction angiography yielded an accurate diagnosis of renal carcinoma in all 5 patients with minimal doses of contrast medium. We conclude that intravenous digital subtraction imaging combined with computerized tomography scanning or ultrasonography yields satisfactory diagnostic and anatomical information for most patients with renal carcinoma.     

Uninephrectomy does not potentiate contrast media nephrotoxicity in the streptozotocin-induced diabetic rat

We studied the effect of radiographic contrast media on renal function in both streptozotocin-induced diabetic rats and normoglycemic rats with reduced renal functional mass. Male Sprague-Dawley induced-diabetic rats and weight-matched controls were divided into unilaterally nephrectomized and intact groups prior to an intravenous challenge with sodium diatrizoate (Urografin) at two dose levels, 1,300 and 2,600 mg iodine/kg. Serum creatinine concentration did not change on the 1st and 3rd day after a dose of 1,300 mg/kg of iodine in normal or induced-diabetic rats. Consequent to a dose of 2,600 mg/kg of iodine, induced-diabetic rats had a significant increase in serum creatinine levels to 0.9 +/- 0.45 mg/dl (control 0.68 +/- 0.11 mg/dl). The observed increase in serum creatinine concentration after treatment with sodium diatrizoate was significantly correlated with the degree of hyperglycemia, but not with prior unilateral nephrectomy. Unilateral nephrectomy, prior to administration of sodium diatrizoate did not potentiate the risk of radiocontrast agent injury in induced-diabetic rats. From these findings, we infer that: (1) streptozotocin-induced diabetes in the rat confers a risk for the development of radiocontrast-induced acute renal failure and (2) as judged by the rise in serum creatinine concentration after exposure, there is an increased risk of acute renal failure associated with a higher dose of radiocontrast material.     

Continuous infusion urography in unilateral hydronephrosis.

In cases of unilateral hydronephrosis the urine concentration of contrast medium, for example diatrizoate, depends on the remaining renal function, the rate of turnover in the obstructed renal pelvis and the function of the contralateral kidney. Contrast medium for a single injection or a short infusion time is rapidly excreted by the normal contraleteral kidney, without allowing high enough plasma levels long enough for sufficient urine concentrations in the hydronephrotic kidney. This excretion rate can be compensated for by continuous infusion urography for several hours with large doses of contrast medium (up to 1,250 ml. 30 per cent diatrizoate). This method was theoretically computerized, tested in animals experiments and clinically used in 11 patients. It can improve the diagnostic possibilites of excretory urography, especially in cases of unilateral obstruction, and can minimize the need for retrograde pyelography with its known complications.     

Tubular nephrotoxicity after intravenous urography with ionic high-osmolal and nonionic low-osmolal contrast media in patients with chronic renal insufficiency

Nephrotoxicity of intravenous contrast media is more frequent and striking in patients with risk factors, the major one being preexisting chronic renal insufficiency. New nonionic low-osmolal contrast media allegedly have less nephrotoxicity than the traditional ionic high-osmolal ones. This was tested for two contrast media in a group of 18 patients with stable chronic renal insufficiency. The urinary excretion of two brush-border enzymes (alanine aminopeptidase, AAP, and gamma-glutamyl transpeptidase, gamma-GT) and of a lysosomal enzyme (N-acetyl-beta glucosaminidase, NAG), functional markers of tubular injury, were measured before and after intravenous urography with an ionic high-osmolal radiocontrast medium, meglumine sodium diatrizoate, or with a non ionic low-osmolal one, iopamidol. Urinary NAG excretion did not change significantly after administration of either contrast media. Urinary AAP and gamma-GT excretion increased significantly (p less than 0.01) after diatrizoate. After iopamidol, only gamma-GT excretion increased significantly (p less than 0.05). Our data suggest that the nonionic low-osmolal radiocontrast medium iopamidol is less toxic to tubules than the ionic high-osmolal medium diatrizoate and that the brush-border enzymes AAP and gamma-GT are sensitive markers for this toxicity.     

黄芪对糖尿病造影剂肾损害的保护作用及机理研究

目的 :探讨黄芪对糖尿病 (DM)造影剂 (CM)肾损害的保护作用及其作用机理。方法 :建立单侧肾切除糖尿病肾病模型 ,比较静脉注入 76 %泛影葡胺 (10mg/kg)前2 4h黄芪灌胃和生理盐水灌胃的大鼠血肌酐、内生肌酐清除率和血浆ET - 1变化情况 ,以及肾脏ET - 1、ET受体A、B(ETR -A、ETR -B)表达情况。结果 :糖尿病大鼠在黄芪灌胃后禁水 2 4h,注射 76 %泛影葡胺 36h后 ,大鼠内生肌酐清除率下降幅度与生理盐水灌胃组相比有统计学意义 (P <0 .0 5 ) ,血浆ET - 1浓度无统计学意义。黄芪灌胃组与生理盐水灌胃组相比 ,肾小管间质ET - 1、ETR -A、ETR -B表达明显低。结论 :黄芪对糖尿病造影剂肾损害的发生有一定的预防作用 ,这种预防作用可能与抑制肾脏局部内皮素系统作用有关。     

MSCT下肢动脉血管成像扫描方案优化

目的探讨128层螺旋CT下肢CTA的最佳扫描方案。方法将60例接受下肢动脉CTA检查的患者随机均分成6组,优化组管电流300mA,层厚0.625mm,对比剂流率4ml/s,注射剂量100ml;其余各组只变动其中1个扫描参数,其他参数同优化组。高毫安组管电流为400mA,低毫安组管电流为200mA,大层厚组层厚为5mm,多对比剂组对比剂注射剂量为130ml,高流率组对比剂流率为4.5ml/s。记录扫描延迟时间;测量腹主动脉水平、股深浅动脉分叉水平、胫前后动脉上段水平、足背动脉水平的CT值;评价各组图像质量,并与优化组进行对比。结果优化组与高毫安组、多对比剂组、高流率组图像质量差异均无统计学意义(P均>0.05);优化组与低毫安组、大层厚组间图像质量差异均有统计学意义(P均<0.05)。结论应用128层螺旋CT机行下肢CTA扫描,采用管电流300mAs、层厚0.625mm、对比剂流率4ml/s、注射剂量100ml时图像质量优良率高,能够满足诊断要求。     

Comparison of the nephrotoxicity between ioversol and iohexol

To evaluate the renal toxicity of intravenous administration of ioversol and iohexol, the urinary N-acetyl-β-glucosaminidase (NAG) to creatinine ratio was measured before and after drip infusion pyelography. Thirty patients received intravenous ioversol and 29 patients received iohexol. The urinary NAG to creatinine ratio tended to increase after respective contrast media: 5% increase in the ioversoltreated, and 8% in the iohexol-treated patients. There were no significant differences in these values; the nephrotoxicity of ioversol appeared to be just as insignificant as that of iohexol.