Agus Sumedi
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摘要

女性,19岁,患有严重全身性神经麻痹,因呼吸衰竭住进重症监护室。他在晚上睡觉时被蛇咬伤,两小时后被送到RSCM医院急诊科。患者在被蛇咬伤后早期主诉恶心、头晕、四肢感觉异常,随后感觉视力不舒服。在急诊观察时,立即给予抗蛇毒血清(AVS) 2瓶(10 ml)加入250 ml生理盐水中1小时,3小时后再给予抗蛇毒血清(AVS) 2瓶加入250 ml生理盐水中1小时,但咬伤后约3小时,患者出现上睑下垂、眼麻痹、四肢麻痹,呼吸短促后出现呼吸骤停。诊断为呼吸衰竭、神经运动性麻痹等。蛇毒中毒。经插管及二次AVS后,患者转至ICU接受机械通气支持及进一步治疗。CVVHDF连续3天,AVS连续6天24小时注射6小瓶。待在ICU 7天,神经麻痹症状改善,但没有进展,患者仍使用呼吸机。然后在ICU第8天和第12天进行Pasmapharesis。脱机过程进展顺利,患者于第14天拔管。患者于第16天出院,神志清醒,心率、血压正常,肌力评分4 ~ 5。我们的结论是,神经毒素毒液破坏了神经末梢突触前的囊泡,使其对AVS和新斯的明产生耐药性。我们怀疑该患者暴露于高剂量和毒性更强的毒液中,这些毒液不断从咬伤部位组织或淋巴循环中释放到血液中,并威胁到康复过程。血浆导入可显著改善神经麻痹和交感神经过度活动,缩短ICU住院时间。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Peranan Plasmafaresis pada Keracunan Bisa Ular Tipe Neurotoksik
Female 19-year old with severe general neuroparalytic, admitted in intensive care unit with respiratory failure. He suffer from snake bite during night sleeping  2 hours before arrived in emergency unit of RSCM hospital. In early after snake bite, patient complained nausea, dizziness, limb parasthesia then felt uncomfortable eyesight. During observation in emergency unit anti venom serum (AVS) was given immediately 2 vial (10 ml) in 250 ml normal saline for an hour and then 2 vials in 250 normal saline in 3 hours ,but about 3 hours post bitten, patient suffer from ptosis, opthalmoplegia and quadriplegia, respiratory shortness followed by respiratory arrest. We diagnosed it as respiratory failure and neuromotoric paralytic  ec. snake  venom intoxication. After intubation and second   dose AVS, patient moved to ICU for mechanical ventilation support and further treatment. We did CVVHDF for three days,  AVS shcedulles 6 vials in 24 hours for 6 days.  Until 7 days stay in ICU there were neuroparalytic improvement but not progressively and patient still on ventilator. Pasmapharesis then  performed at 8thand 12th day in ICU. Weaning process going on smoothly and patient  extubated at 14th day. Patient discharged from ICU at 16th day with fully aware, normal heart rate and blood pressureand score muscle strength is 4 until 5. We concluded that the neurotoxin venom in this case destructed  vesicles presynaptic of nerve terminalmake resistant  to AVS and neostigmin. We suspect this patient was exposedto high dose and more toxic venom where  released continuously from bite site tissue or lymph circulation to blood and  threaten recovery process. Plasmapharesis improve neuroparalytic and sympathetic overactivity significantlyand decrease lenght of stay in ICU.
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