背景:氰化物中毒对在住宅或工作场所火灾中暴露于烟雾的烧伤患者构成重大威胁,导致中枢神经系统功能障碍,血流动力学不稳定,心血管衰竭,和死亡。及时服用有效的解毒剂至关重要。羟基钴胺,维生素B12的一种形式,是治疗氰化物毒性的黄金标准,通过与氰化物分子结合并将其转化为无毒的氰钴胺,并被肾脏消除。这种机制不同于以前的氰化物解毒剂,诱导高铁血红蛋白与氰化物结合的形成。最近的案例研究报道了羟钴胺给药后高铁血红蛋白水平升高,引起人们对其安全性的担忧。目前的研究调查了在单一机构烧伤单位接受羟钴胺治疗的烟雾吸入患者,以期增强我们对氰化物解毒剂治疗复杂性的理解。
方法:机构委员会批准后,进行了一项回顾性队列研究.我们的样本包括2013年至2023年在单一机构接受吸入性损伤的烧伤患者,并因怀疑氰化物毒性而接受羟钴胺治疗。我们还分析了未使用羟钴胺治疗的类似吸入性损伤患者的匹配对照队列。我们分析了高铁血红蛋白水平的变化和峰值,乳酸水平,血尿素氮(BUN)和肌酐,呼吸机日,%身体总表面积(TBSA),各种类型的药物和敷料,和死亡率。统计分析包括t检验,卡方,线性和逻辑回归,和相关分析。
结果:在研究中,2013年至2023年,36例疑似吸入性损伤患者在洛杉矶总医院(LAG)烧伤单位接受了羟钴胺治疗,与32例未经羟钴胺治疗的吸入性损伤对照患者相匹配。人口统计学和基线特征显示两组之间没有统计学上的显着差异,包括年龄,性别,BMI,和%TBSA。在初始阶段没有发现显著差异,最后,峰值,或高铁血红蛋白水平的变化。该研究还显示,初始乳酸水平没有显着差异,死亡率,肾功能测试,呼吸机日,手术,或使用药物/治疗(例如,西瓦丁敷料,维生素C)在两组之间。当控制协变量时,多元线性回归分析(年龄,性别,和%TBSA)表明,羟钴胺的给药与高铁血红蛋白或死亡率的变化没有显着相关。增加TBSA%,然而,与乳酸水平升高有关。
结论:我们的研究试图评估合并吸入性损伤的烧伤患者中使用羟钴胺的潜在风险。与我们最初的假设相反,我们发现高铁血红蛋白血症没有统计学上的显著差异,乳酸水平,死亡率,或肾功能。其他因素的影响,如高铁血红蛋白血症诱导药物或羟钴胺素对共同血氧饱和度的干扰,增加了复杂性。尽管在某些情况下观察到高铁血红蛋白水平升高,其临床意义有限。然而,这项研究的局限性,特别是罕见的吸入性损伤病例,关注氰化物的毒性,保证考虑。需要进一步的研究来全面阐明羟钴胺给药对烧伤患者预后的影响。
BACKGROUND: Cyanide poisoning poses a significant threat to burn patients exposed to smoke in residential or workplace fires, leading to central nervous system dysfunction, hemodynamic instability, cardiovascular collapse, and death. Prompt administration of an effective antidote is critical. Hydroxocobalamin, a form of vitamin B12, is the gold standard treatment for cyanide toxicity, by binding to cyanide molecules and converting them into non-toxic cyanocobalamin that is eliminated by the kidneys. This mechanism is distinct from previous cyanide antidotes, which induce the formation of
methemoglobin to bind to cyanide. Recent case studies have reported elevated
methemoglobin levels after hydroxocobalamin administration, raising concerns regarding its safety. The current study investigates smoke inhalation patients treated with hydroxocobalamin at a single institution Burn Unit in hopes of enhancing our understanding of the complexities surrounding cyanide antidote therapy.
METHODS: After Institutional Board Approval, a retrospective cohort study was conducted. Our sample comprised burn patients with inhalation injury admitted to a single institution from 2013 to 2023 and treated with hydroxocobalamin for suspected cyanide toxicity. We also analyzed a matched control cohort of similar patients with inhalation injury not treated with hydroxocobalamin. We analyzed changes and peaks in
methemoglobin levels, lactate levels, blood urea nitrogen (BUN) and creatinine, ventilator days, % total body surface area (TBSA), various types of medications and dressings, and mortality. Statistical analyses included t-tests, chi-square, linear and logistic regressions, and correlation analysis.
RESULTS: In the study, 36 patients with suspected inhalation injury were treated with hydroxocobalamin at the Los Angeles General (LAG) Burn Unit from 2013 to 2023, who were matched to 32 control patients with inhalation injury who were not treated with hydroxocobalamin. Demographic and baseline characteristics showed no statistically significant differences between the groups, including age, gender, BMI, and %TBSA. No significant differences were found in initial, final, peak, or change in
methemoglobin levels. The study also revealed no significant disparities in initial lactate levels, mortality, kidney function tests, ventilator days, surgeries, or use of medications/treatments (e.g., Silvadene dressings, Vitamin C) between the two groups. When controlling for covariates, multiple linear regression analysis (age, gender, and %TBSA) indicated that hydroxocobalamin administration was not significantly associated with changes in methemoglobin or mortality. Increased %TBSA, however, was linked to elevated lactate levels.
CONCLUSIONS: Our investigation sought to assess the potential risks associated with hydroxocobalamin administration in burn patients with concomitant inhalation injury. Contrary to our initial hypothesis, we found no statistically significant differences in methemoglobinemia, lactate levels, mortality, or kidney function. The influence of other factors, such as methemoglobinemia-inducing drugs or hydroxocobalamin\'s interference with co-oximetry, adds complexity. Although elevated
methemoglobin levels were observed in some cases, their clinical significance was limited. However, this study\'s limitations, particularly the rarity of inhalation injury cases with concern for cyanide toxicity, warrant consideration. Further research is required to comprehensively elucidate the impact of hydroxocobalamin administration on burn patients\' outcomes.