RESUMO
Objective? To?systematically?analyze?the?effect?of?haemoperfusion?(HP)?combined?with?continuous?veno-veno?haemofiltration?(CVVH)?in?the?treatment?of?the?patients?with?paraquat?poisoning?(PQP).? Methods? Words?of?paraquat,?poisoning,?continuous?venous?hemofiltration,?hemoperfusion,?hemodiafiltration?in?Chinese?and?paraquat,?poisoning,?intoxication,?haemofiltration,?continuous?venovenous?haemofiltration,?haemoperfusion?in?English?were?chosen?as?keywords,?the?Chinese?and?English?literatures?about?acute?PQP?treated?with?HP?combined?with?CVVH?published?in?Wanfang?database,?CNKI,?CBM,?VIP?database,?PubMed,?Embase,?Cochrane?Library?were?searched?by?computer,?and?the?retrieval?time?was?from?the?establishment?of?the?database?to?July?2018.?The?experimental?group?was?treated?with?HP?combined?with?CVVH,?while?the?control?group?was?treated?with?HP?alone.?Besides,?the?outcome?indicators?included?mortality,?survival?time?of?dead?patients?(the?patient's?time?from?exposure?to?poison?to?death),?serum?creatinine?(SCr),?alanine?aminotransferase?(ALT),?arterial?partial?pressure?of?oxygen?(PaO2),?and?incidence?of?circulatory?and?respiratory?failure.?The?literature?data?were?extracted?by?two?researchers?independently,?the?quality?of?the?literature?was?evaluated? according?to?the?modified?Jadad?score?table?or?Newcastle-Ottawa?scale?(NOS),?and?the?Meta-analysis?was?carried?out?by?RevMan?5.3?software;?and?the?stability?of?the?results?of?Meta-analysis?was?tested?by?sensitivity?analysis.?Further,?the?publication?bias?was?analyzed?through?drawing?a?funnel?diagram.? Results? Finally,?20?articles?were?included,?with?18?in??Chinese?and?2?in?English.?Among?them,?6?were?randomized?controlled?trial?(RCT)?and?14?were?case-control?studies.?Furthermore,?a?total?of?2?870?patients?were?involved,?with?1?558?in?the?control?group?and?1?312?in?the?experimental?group.?Meta-analysis?showed?that?the?mortality?rate?of?patients?in?the?experimental?group?was?significantly?lower?than?that?in?the?control?group?[odds?ratio?(OR)?=?0.55,?95%?confidence?interval?(95%CI)?=?0.42?to?0.73,?P <?0.000?1],?the?patients'?time?from?toxin?exposure?to?death?was?significantly?longer?than?that?in?the?control?group?[standard?mean?difference?(SMD)?=?2.16,?95%CI?=?1.46?to?2.86,?P?<?0.000?01).?In?the?course?of?treatment,?the?peak?value?of?SCr?in?the?experimental?group?was?significantly?lower?than?that?in?the?control?group?(SMD?=?-0.53,?95%CI?=?-0.65?to?-0.42,?P?<?0.000?01),?and?the?peak?value?of?ALT?was?also?decreased?(SMD =?-0.72,?95%CI?=?-0.99?to?-0.44,?P?<?0.000?01).?Besides,?there?was?no?significant?difference?in?PaO2?between?the?two?groups?on?the?3rd?day?of?treatment?(SMD =?0.15,?95%CI?=?-0.19-0.49,??P?=?0.40),?but?on?the?7th?day,?PaO2?in?the?experimental?group?was?significantly?higher?than?that?in?the?control?group?(SMD?=??0.23,?95%CI =?0.29?to?0.98,?P?=?0.000?3).?Furthermore,?the?incidence?of?circulatory?failure?in?the?experimental?group?was?significantly?lower?than?that?in?the?control?group?(OR =?0.26,?95%CI?=?0.19?to?0.37,?P?<?0.000?01),?but?the?incidence?of?respiratory?failure?was?significantly?higher?than?that?in?the?control?group?(OR =?4.14,?95%CI?=?3.00?to?5.72,?P?<?0.000?01).?The?influence?of?heterogeneity?on?statistical?results?was?excluded?in?the?sensitivity?analysis,?and?funnel?plot?diagram?was?applied?to?indicate?the?publication?bias?of?mortality?and?survival?time?of?the?dead?patients.? Conclusion? Combined?with?HP?alone,?HP?combined?with?CVVH?could?better?improve?liver?and?kidney?function?and?oxygenation?state?of?PQP?patients,??reduce?the?incidence?of?early?circulatory?failure,?prolong?the?survival?time?and?reduce?the?death?rate?of?PQP?patients.
RESUMO
The high mortality of paraquat (PQ) poisonings is mainly due to the lack of effective treatments. The optimal method of extracorporeal removal of paraquat is often a matter of debate. Due to the lack of well-designed studies, we are often left with circumstantial evidence, and we must exercise our best clinical judgment as to whether extracorporeal paraquat removal is beneficial and if so, by what method. It is clear, however, that rapidity in paraquat removal is beneficial. Due to the urgent nature of treatment for paraquat poisoning, there may never be well-designed evidence-based studies to help guide us. In the meantime, we must continue to use less than ideal evidence and our own experience to guide our decision-making process. Most toxicologists recommend rapid initiation of charcoal haemoperfusion (CHP) to lower plasma PQ levels and to limit pulmonary and other organs uptake of PQ.
RESUMO
The high mortality of paraquat (PQ) poisonings is mainly due to the lack of effective treatments. Most toxicologists recommend rapid initiation of charcoal haemoperfusion (CHP) to lower plasma PQ levels and to limit pulmonary and other organs uptake of PQ. Although there are considerable evidences of CHP efficacy in the reversion of the fatal outcome resulting from PQ poisonings, the usefulness of this therapy has been the subject of significant controversy with several evidences published in the literature showing a lack of clinical benefit in numerous cases. Considering that the blood concentration at a given time is directly related to clinical outcome, the rebound in plasma paraquat concentration after haemoperfusion may be partly relate to the poor clinical benefit, but may indicate the necessity for prolonged haemoperfusion. Continuous rather than intermittent haemoperfusion has been advocated for treatment of paraquat poisoning. However, 24h daily conventional pump driven haemoperfusion is usually impossible to carry out due to bleeding complications. Plasmapheresis is also a blood purification process. Unselective therapeutic plasma exchange is the first technology used for therapeutic apheresis (TA). However, limited efficacy by restricted plasma volume that can be exchanged in a single session is one of the severe limitations. To further increase the clearance of target molecules, plasma perfusion (PP) techniques was developed. modification of the conventional plasma perfusion in patients with paraquat poisoning has been reported and plasma levels of paraquat were reduced effectively.