{"id":860,"date":"2018-08-22T19:07:03","date_gmt":"2018-08-22T16:07:03","guid":{"rendered":"https:\/\/tatd.org.tr\/tatdtoks\/2021\/09\/15\/zehirlenmelerde-ekstrakorporeal-tedaviler-yazi-dizisi-metformin\/"},"modified":"2021-11-10T22:35:23","modified_gmt":"2021-11-10T19:35:23","slug":"zehirlenmelerde-ekstrakorporeal-tedaviler-yazi-dizisi-metformin","status":"publish","type":"post","link":"https:\/\/tatd.org.tr\/toksikoloji\/2018\/08\/22\/zehirlenmelerde-ekstrakorporeal-tedaviler-yazi-dizisi-metformin\/","title":{"rendered":"Zehirlenmelerde Ekstrakorporeal Tedaviler Yaz\u0131 Dizisi \u2013 Metformin"},"content":{"rendered":"<h2><strong><u>METFORM\u0130N<\/u><\/strong><\/h2>\n<h3><\/h3>\n<h3><strong>Genel : <\/strong><\/h3>\n<ul>\n<li>Tip II DM\u2019de en \u00e7ok re\u00e7ete edilen oran antidiyabetik.<\/li>\n<li>Glukoneogenezi inhibe eder, h\u00fccresel glukoz al\u0131m\u0131n\u0131 kolayla\u015ft\u0131r\u0131r ve ins\u00fclin direncini azalt\u0131r.<\/li>\n<li>MW :165 Da<\/li>\n<li>Oral biyoyararlan\u0131m %55<\/li>\n<li>Proteine ba\u011flanmaz.<\/li>\n<li>Da\u011f\u0131l\u0131m hacmi 1-5 L\/kg<\/li>\n<li>B\u00fcy\u00fck oran\u0131 b\u00f6breklerden de\u011fi\u015fmeden at\u0131l\u0131r.<\/li>\n<li>Terap\u00f6tik dozda pik d\u00fczeyi 1.5-3.0 mg\/L<\/li>\n<li>Eliminasyon yar\u0131 \u00f6mr\u00fc multifazik \u2013 4-8 saati takiben 20 saatlik terminal eliminasyon.<\/li>\n<\/ul>\n<h3><\/h3>\n<h3><strong>Klinik :<\/strong><\/h3>\n<ul>\n<li><strong>Metformin ili\u015fkili laktik asidoz (MALA) :<\/strong> metformin maruziyeti ile ili\u015fkili olarak laktat d\u00fczeyi &gt; 5 mmol\/L ve pH &lt; 7.35 olmas\u0131.<\/li>\n<li><strong>\u0130nsidental (kronik) MALA :<\/strong> metformin birikimi sonucu laktat \u00fcretiminde\/klirensinde de\u011fi\u015fiklik sonucu.<\/li>\n<li><strong>Akut (kas\u0131tl\u0131) MALA (MILA- metforminin ind\u00fckledi\u011fi laktik asidoz) :<\/strong> akut doz a\u015f\u0131m\u0131 sonras\u0131 direkt metforminin sorumlu oldu\u011fu laktik asidoz.<\/li>\n<li>Mekanizma : laktat\u0131 pir\u00fcvata d\u00f6n\u00fc\u015ft\u00fcren pir\u00fcvat karboksilaz\u0131 inhibe ederek h\u00fccresel solunumu bozar. =&gt; artm\u0131\u015f laktat \u011fretimi + azalm\u0131\u015f laktat metabolizmas\u0131 = tip B laktik asidoz<\/li>\n<li>Metformin toksisitesine yatk\u0131nl\u0131k sa\u011flayan en \u00f6nemli etken b\u00f6brek fonksiyonlar\u0131nda bozulma.<\/li>\n<li>&gt;20-50 mg\/L d\u00fczeyi = k\u00f6t\u00fc prognozla ili\u015fkili olabilece\u011fi g\u00f6sterilmi\u015f. Ama kan\u0131tlanmam\u0131\u015f.<\/li>\n<\/ul>\n<h3><\/h3>\n<h3><strong>Y\u00f6netim :<\/strong><\/h3>\n<ul>\n<li>Res\u00fcsitasyon, destek tedavisi.<\/li>\n<li>Erken ba\u015fvuruda gastrointestinal dekontaminasyon.<\/li>\n<li>Bikarbonat \u2013 hicrei\u00e7i asidozu artt\u0131rabilir, oksihemoglobin e\u011frisini sola kayd\u0131rabilir, sodyum y\u00fck\u00fcn\u00fc artt\u0131rabilir.<\/li>\n<li>Metformin zehirlenmeli hastalarda ECTR genellikle uygulan\u0131yor ancak \u00f6neriler a\u00e7\u0131k de\u011fil.<\/li>\n<\/ul>\n<h3><\/h3>\n<h3><strong>Literat\u00fcr tarama :<\/strong><\/h3>\n<ul>\n<li>Medline, Embase, Cochrane systematic Reviews ve Cochrane Central (12 Temmuz 2012).<\/li>\n<li>Veritabanlar\u0131nda metformin veya glukofaja ek olarak; diyaliz veya hemodiyaliz veya hemoperf\u00fczyon veya plazmaferez veya plazma de\u011fi\u015fimi, de\u011fi\u015fim transf\u00fczyon veya hemofiltrasyon veya hemodiyafiltrasyon veya ekstrakorporeal tedavi veta CRRT tarand\u0131.<\/li>\n<li>EAPCCT ve NACCT y\u0131ll\u0131k toplant\u0131 tutanaklar\u0131 manuel olarak tarand\u0131 (2002-2012).<\/li>\n<li>Google scholar ve eri\u015filen makalelerin kaynak\u00e7alar\u0131 tarand\u0131.<\/li>\n<li>Literat\u00fcr tarama 1 Kas\u0131m 2014\u2019te g\u00fcncellendi.<\/li>\n<\/ul>\n<h3><\/h3>\n<h3><strong>Sonu\u00e7 : <\/strong><\/h3>\n<p>175 makale dahil edildi : 1 retrospektif g\u00f6zlemsel \u00e7al\u0131\u015fma, 11 toplu analizli (aggregate analysis) kontrols\u00fcz kohort \u00e7al\u0131\u015fma, hasta d\u00fczeyinde bilgilerin \u00e7\u0131kart\u0131lmas\u0131na olanak veren 160 vaka bildirimi veya vaka serisi, son d\u00f6nem b\u00f6brek yetmezli\u011fi \u00fczerine 3 farmakokinetik \u00e7al\u0131\u015fma.<\/p>\n<h3><\/h3>\n<h3><strong>\u00d6neriler :<\/strong><\/h3>\n<p><strong>1. Genel : Ciddi metformin zehirlenmesinde ECTR \u00f6nerilir (1D).<\/strong><\/p>\n<p>Gerek\u00e7e : MALA\u2019da mortalite %30-50 aras\u0131nda bildirilmi\u015f.<\/p>\n<p>ECTR metforminin temizlenmesinden ayr\u0131 olarak asideminin, hiperlaktateminin, elektrolit bozukluklar\u0131n\u0131n da d\u00fczeltilmesinde ve bozulmu\u015f b\u00f6brek fonksiyonlar\u0131n\u0131 destekleyici role sahip.<\/p>\n<p><strong>2. ECTR Endikasyonlar\u0131 :<\/strong><\/p>\n<p>\u015eu durumlarda ECTR \u00f6nerilir:<\/p>\n<ol style=\"list-style-type: upper-alpha\">\n<li><strong>Laktat d\u00fczeyi &gt; 20 mmol\/L (1D)<\/strong><\/li>\n<li><strong>Kan pH <\/strong>\u00a3<strong> 7.0 (1D)<\/strong><\/li>\n<li><strong>Standart tedavi (destek tedavisi, bikarbonat) yetersiz kal\u0131rsa (1D)<\/strong><\/li>\n<\/ol>\n<p>\u015eu durumlarda ETCR tavsiye edilir :<\/p>\n<ol style=\"list-style-type: upper-alpha\">\n<li><strong>Laktat d\u00fczeyi &gt; 15-20 mmol\/L (2D)<\/strong><\/li>\n<li><strong>Kan pH &lt; 7.0-7.1 (2D)<\/strong><\/li>\n<\/ol>\n<p>ECTR ba\u015flanma e\u015fi\u011fini d\u00fc\u015f\u00fcren komorbid durumlar :<\/p>\n<ol style=\"list-style-type: upper-alpha\">\n<li><strong>\u015eok (1D)<\/strong><\/li>\n<li><strong>Bozulmu\u015f b\u00f6brek fonksiyonlar\u0131 (1D)<\/strong><\/li>\n<li><strong>Karaci\u011fer yetmezli\u011fi (2D)<\/strong><\/li>\n<li><strong>Bilin\u00e7 d\u00fczeyinde azalma (2D)<\/strong><\/li>\n<\/ol>\n<p><strong>ECTR karar\u0131 tek ba\u015f\u0131na fazla miktarda metformin al\u0131nmas\u0131na dayanarak verilmemelidir (1D)<\/strong><\/p>\n<p>Akut metformin doz a\u015f\u0131m\u0131nda metformin d\u00fczeyinin prognostik de\u011feri tam bilinmiyor, metforminin doz-yan\u0131t oran\u0131 bilinmiyor. Ayr\u0131ca terap\u00f6tik dozlarda kronik metformin kullan\u0131m\u0131nda da toksisite geli\u015febilece\u011finden <strong>ECTR i\u00e7in e\u015fik metformin de\u011feri belirlenmemi\u015f<\/strong>.<\/p>\n<h3><strong>3. ECTR\u2019nin kesilmesi :<\/strong><\/h3>\n<p><strong>Laktat d\u00fczeyi &lt; 3mmol\/L (27 mg\/dL) ve ph&gt;7.35 (1D) olunca.<\/strong><\/p>\n<h3><strong>4. ECTR se\u00e7imi :<\/strong><\/h3>\n<p><strong>Ba\u015flang\u0131\u00e7 ECTR seans\u0131 i\u00e7in bikarbonat tamponu ile IHD tercih edilir (1D) ancak hemodiyaliz imkan\u0131 yok ise CRRT uygun bir alternatiftir (2D).<\/strong><\/p>\n<p><strong>\u0130lk ECTR seans\u0131ndan sonra, e\u011fer hala gerek var ise hem hemodiyaliz (1D), hem de CRRT (1D) uygundur. <\/strong><\/p>\n<h3><strong>Kaynak : <\/strong><\/h3>\n<ol>\n<li>Calello, D. P., Liu, K. D., Wiegand, T. J., Roberts, D. M., Lavergne, V., Gosselin, S., et al. (2015). Extracorporeal Treatment for Metformin Poisoning. <em>Critical Care Medicine<\/em>, <em>43<\/em>(8), 1716\u20131730. <a href=\"http:\/\/doi.org\/10.1097\/CCM.0000000000001002\">http:\/\/doi.org\/10.1097\/CCM.0000000000001002<\/a><\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"<p>METFORM\u0130N Genel : Tip II DM\u2019de en \u00e7ok re\u00e7ete edilen oran antidiyabetik. Glukoneogenezi inhibe eder, h\u00fccresel glukoz al\u0131m\u0131n\u0131 kolayla\u015ft\u0131r\u0131r ve ins\u00fclin direncini&hellip;<\/p>\n","protected":false},"author":1380,"featured_media":1795,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[10014],"tags":[143,150,202,283,449],"class_list":["post-860","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-akademik-blog-yazisi","tag-ekstrakorporeal-tedaviler","tag-extrip","tag-intoksikasyon","tag-metformin","tag-zehirlenme"],"acf":[],"_links":{"self":[{"href":"https:\/\/tatd.org.tr\/toksikoloji\/wp-json\/wp\/v2\/posts\/860","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/tatd.org.tr\/toksikoloji\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/tatd.org.tr\/toksikoloji\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/toksikoloji\/wp-json\/wp\/v2\/users\/1380"}],"replies":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/toksikoloji\/wp-json\/wp\/v2\/comments?post=860"}],"version-history":[{"count":0,"href":"https:\/\/tatd.org.tr\/toksikoloji\/wp-json\/wp\/v2\/posts\/860\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/toksikoloji\/wp-json\/wp\/v2\/media\/1795"}],"wp:attachment":[{"href":"https:\/\/tatd.org.tr\/toksikoloji\/wp-json\/wp\/v2\/media?parent=860"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/tatd.org.tr\/toksikoloji\/wp-json\/wp\/v2\/categories?post=860"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/tatd.org.tr\/toksikoloji\/wp-json\/wp\/v2\/tags?post=860"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}