two cases of methemoglobinemia
TRANSCRIPT
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Case of xenobiotic induced cyanosis
Dr.s.a.jayakumar IMCU chief -Prof. Dr.Chenthil
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CASE 1Mr.Suresh 35/male
Admitted on 24.12.2010
Alleged h/o ingestion of some oil ?carburetor oil
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He was found lying unconscious with a can of oil beside him; He had vomitted and he was covered with
vomitus ;
Past history : not a DM/HT/IHD/ BA/TB patient
Personal history : chronic alcoholic > 15 yrs -360 ml /day
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Unconscious GCS E1 V1 M1Tachypneic Dyspnoeic Cyanosis + fingers toes , lips & tongue
Pulse : 110/mt BP : 80/60 mmhg RR: 30/mt
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SpO2 :85 % ABG
p H 7.36 p O2- 107 p CO2 -32.6
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Immediately patient was intubated & put on ventilator ;on ACMV mode;with FiO2 100%;
IVFDopamine infusion started at 10µg/kg/mt
Inj .methylene blue 1 mg/kg infusion given
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Hb – 12.0 g/dl;TC- 9600; P80 ;L20;ESR - 5/12 mm;PCV-36%;Platelets -1.8 lakhs
RBS – 122 mg/dl;Urea- 26 mg/dl;Creatinine – 0.8 mg/dl
Na-138meq; k-4.8 meqCl -96meq;Hco3-22meq
Serum meth Hb -- ++
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course after treatment;
initially patient improved consciuosness after 2 doses of methylene blue ;Cyanosis improved;Obeying commands ;
Within 2 days ,he developed fever ,progressive dyspnea ,extensive crepitations and despite antibiotics ,ventilatory support & other supportive measures died on the third day of admission ;
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Case 2 Mrs.Devi , 28 yrs female
Admitted on 13.03.2011 ;
Alleged to have consumed some amount of a
product ‘ hytro-zyme ‘
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Nitrobenzene
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She was found unconscious in her house ,
with deep irregular breathing and secretions from mouth ;
Past history : not a DM/HT/IHD/BA/ patient
Personal history : regular menstrual cycles ; takes mixed diet
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Unconscious E4 V1 M4DyspneicTachypneicCyanosis of lips,tongue ,fingers &
toes
Pulse 100/mt;BP- 90/60 mmhg ;RR- 34/mt
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SpO2 -80%
ABG p H 7.4 p O2 128 p CO2 34
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Immediately patient was intubated & connected to ventilator –ACMV mode with FiO2 -100 %;
IVF
Inj.methylene blue 1mg/kg ;
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Hb-10.2g/dl;TC- 9800; P86 L14;ESR-10/22PCV-30%;Platelet :1.5 lakhs;
RBS- 131mg/dl;Urea -31Creatinine -1.1
Na 134; K 4.5Cl -98; Hco3-22
Serum meth hb +
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Course after treatment
Patients SpO2 was constantly around 80 % despite ventilatory support ;Consciousness didn’t recover ;
She developed progressive hypotension and stayed unconscious ;
After 2 days despite all available measures she died
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Case 1 ingestion of ? carburetor oil –
organic solvent cyanosis hypotension Meth
hemoglobinemia Initial improvement
with methylene blue
Case 2 Ingestion of nitro
benzene
cyanosis, Hypotension Meth
hemoglobinemia No improvement
despite treatment ;
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cyanosis
high flow O 2 ( improves)
(no improvement )
met hb conc.
< 25% >25%
asymptom. Symptom methyleneblue
no respon.
respon
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Basics Reversible binding of oxygen to
hemoglobin is ‘oxygenation’;Whereas oxidised hemoglobin is a
state where ferrous iron is converted to ferric
iron; such a hemoglobin (oxidised
hemoglobin)is called “meth hemoglobin “
Normally met Hb level is in the body < 1 % ;
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Protective mechanisms
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When there is a basic defect in the protective mechanisms
( HEREDITARY ) or When there is an external agent which
overwhelms the protective
mechanisms ( ACQUIRED )
clinically significant methhemoglobinemia results
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HEREDITARY METHHEMOGLOBINEMIA
Deficiency of diaphorase I(NADH met Hb reductase):
type 1 - 85% ; autosomal recessive ; only mature red cells are affected;
type 2 - 10 -15 % of cases ; all cells are affected ;
developmental delay & early death ;
Hemoglobin M disease : autosomal dominant ; either alpha or beta
globin affected
other causes: pyruvate kinase deficiency G6PD deficiency
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METH HAEMOGLOBINEMIA
Acetanilidp-Amino salicylic acidAniline dyes
Benzene derivativesClofazimine Chlorates
ChloroquineDapsoneBenzocaineLidocainePrilocaineMenadione
MetoclopramideMethylene blue*
Naphthoquinone
NaphthaleneNitritesAmyl nitriteFarryl nitriteSodium nitrite
NitroglycerinNitric oxideNitrobenzeneParaquatPhenacetinPhenazopyridine
PrimaquineResorcinol
Sulfonamides
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Pathogenesis
Met Hb causes - decreased available O2 carrying
capacity ; -increased affinity of unaltered Hb FOR o2
,shifting the oxygen dissociating curve to left ;
Cyanosis develops when 1.5 g/dl met hb is present ;
Also depends on the rate of formation and elimination
of MetHb
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1 - < 3 % Asymptomatic
3 – 15 % Slate grey color
Low SpO2
15 – 20 % Cyanosis Chocolate brown blood
20 – 50 % Dyspnea , dizziness,exercise intolerance ,syncope ,headache weakness
50 – 70 % Tachypnea ,arrhythmia ,metabolic acidosis ,seizures ,CNS depression ,Coma
> 70% Grave hypoxia ,death
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Investigations PULSE OXIMETER :
-non invasive method; measures SpO2 ;
-2 light emitting diodes –measure absorbance at peak
wavelength for oxy & deoxy Hb – 940 & 660 nm respectively ;
-presence of meth Hb ,sulf Hb interfere with the accuracy of pulse oximeter;
presence of methylene blue too interferes
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LP 15 defibrillator /pulse
oximeter ;
Advantage of monitoring meth hemoglobin
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ABG
In cases of meth hemoglobinemia when there is cyanosis
and the SpO2 is abnormal with the help of ABG we can find out
that the PO 2 normal ; as the ABG is not affected by the abnormal hemoglobin
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Co oximeters :
it is a spectrometer ;
uses 4 wavelengths of light;
measures oxyHb, deoxyHb, carboxyHb
& metHb
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Met hb assay Quantitative test is by EVELYN MALLOY
method Take 2 aliquots of blood 1 & 2 ; 1) Absorbance measured at 630nm
(A1);add pot.cyanide; measure again absorbance(A2) ; if any met hb + the cyanide will abolish the absorbance peak
2)add pot.ferricyanide;all Hb converted to metHb;now measure absorbance before(A3) and after adding cyanide(A4) ;
% of met Hb = ( A1-A2)×100 / (A3-A4)
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Treatment: 1.methylene blue; 1-2mg/kg infused over 5
mts ;not exceed 7mg/kg; clinical improvement seen within 1 hr ; contraindicated in G6PD deficiency 2. Hyperbaric oxygen ;3.Exchange transfusion ;NOTE: Blood transfusions and ascorbic acid are of
unproven value ;
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CERTAIN INTERESTING ANECDOTES : 1. Ernst Felix Immanuel Hoppe-Seyler
german scientist first described meth hemoglobin ;
2. hyperlipidemia may spuriously cause elevated methb levels ;
3. foods having high nitrate content which might cause methb
cauliflower carrot spinach & broccoli;
4.Well water with high nitrate content can cause meth Hb ;
5.Dapsone induced meth hemoglobinemia ; -- use cimetidine as it prevents the
formation of toxic metabolite of dapsone