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甘露醇为什么不能用于肺水肿？还有哪些禁忌？

2022-04-10 网络 网络

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甘露醇是一种糖醇，由于其注射液为高渗溶液，且主要以原形从肾脏排出，因此常被用于组织脱水和渗透性利尿。

甘露醇是一种糖醇，由于其注射液为高渗溶液，且主要以原形从肾脏排出，因此常被用于组织脱水和渗透性利尿。

 

甘露醇作用机制

由于甘露醇不易由毛细血管渗入组织，因而聚集于血管内，能够增加血管内胶体渗透压；又由于不能透过完整的血脑屏障、血眼屏障，不增加脑内和眼内压。因此，增加的血浆胶体渗透压可以将水从脑实质、玻璃体中“拽”进血管，然后水与甘露醇一起经肾排出，因而可以用于降低颅内压和眼内压。同样基于这个原理，对于急性肾损伤少尿期的患者，甘露醇可以将水带出，同时也可以带出水溶性药物或毒性水溶物。

 

基于以上作用机制和临床实践，甘露醇常见适应症为：

 

1.  降低颅内压

2.  降低眼内压

3.  急性肾损伤少尿期时利尿

4.  促水溶性药物排泄，以防止药物中毒

5.  作为辅助性利尿措施，治疗肾病综合征、肝硬化腹水，尤其伴有低蛋白血症时

6.  经尿道做前列腺切除术（灌洗）

7.  肠道准备（口服）

（注：除6.7以外，给药方式均为静脉输注）

 

不过，大家也许注意到了，在说明书中，甘露醇有一条禁忌“肺水肿”。为什么甘露醇不能用于肺水肿呢？

 

首先，我们来简单回顾一下肺水肿。肺水肿是指过量液体积聚于肺间质，且可以溢入肺泡腔内。

 

肺水肿按照发病机制不同可以分为心源性肺水肿和非心源性肺水肿。

 

心源性肺水肿的最常见病因为急性失代偿性心力衰竭(ADHF)：由于心脏充盈压急剧升高，导致液体迅速积聚于肺间质和/或肺泡腔；非心源性肺水肿则是由肺毛细血管压升高以外的其他因素所导致的。

 

甘露醇不能用于肺水肿，是因为它会增加血容量因而使肺水肿进一步加重。具体机制有以下两条：

 

1.  当静脉输注甘露醇时，需要在较短时间之内快速输注才起效，因而会导致血容量在短时间内增加，加重急性肺水肿；

2.  静脉输注甘露醇后，大量液体在渗透压的作用下，从细胞内转移到细胞外，导致血容量在短时间内剧增，加重急性肺水肿。

 

图：静脉输注甘露醇引起急性肺水肿加重机制

 

 

图片

 

除了肺水肿，甘露醇还有什么禁忌，又是为什么呢？

 

1.    严重肺淤血/甘露醇治疗开始后出现进行性心力衰竭或肺充血

原因：同上，甘露醇导致血容量增加，使心力衰竭、肺充血或肺淤血进一步加重。

2.    颅内活动性出血，颅内手术时除外

原因：甘露醇可以透过受损的血脑屏障，进入病灶区脑组织内，导致脑水肿加重。

3.    严重脱水

原因：甘露醇作为利尿剂导致脱水进一步加重。

4.    已确诊为急性肾小管坏死的无尿患者

原因：对于无尿患者甘露醇无法排出，大量甘露醇聚集于血管内可能会导致血浆高渗、容量超负荷、高血钾（具体机制不明，可能与钾离子从细胞内转移到细胞外、组织脱水从而引起血管内稀释性酸中毒有关）。

5.    对甘露醇存在超敏反应

 

参考文献：

1.    甘露醇药物使用说明书

2.    Tenny S, Patel R, Thorell W. Mannitol. [Updated 2022Feb 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearlsPublishing; 2022 Jan-. Available from:https://www.ncbi.nlm.nih.gov/books/NBK470392/

3.    Ware LB, Matthay MA. Clinical practice. Acute pulmonaryedema. N Engl J Med. 2005 Dec 29;353(26):2788-96. doi: 10.1056/NEJMcp052699.PMID: 16382065.

4.    Vanholder R., Sever S.M., (2021) Crush-related acutekidney injury. In J. P. Forman (Ed.) UpToDate. Retrieved formhttps://www.uptodate.com/contents/zh-Hans/crush-related-acute-kidney-injury

5.    Pinro S. D., Garan A. R., (2022) Pathophysiology ofcardiogenic pulmonary edema. In T. F. Dardas (Ed.) UpToDate. Retrieved form https://www.uptodate.com/contents/pathophysiology-of-cardiogenic-pulmonary-edema?search=pulmonary%20edema&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2

 

撰写 | 小江丰
编辑 | 爱磕cp的年糕
授权转载、投稿等请联络梅斯医学管理员
克里@梅斯医学（微信号：wxid_uxd7pgpliaio22）

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    2022-05-01 赛华佗

    #肺水肿#

    0

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    2022-04-12 medscijoin

    #甘露醇#

    0

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    2022-04-12 小华子

    #水肿#

    0

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    2022-04-12 医者仁心

    #禁忌#

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=1215986, encodeId=10dc1215986af, content=<a href='/topic/show?id=968a8214192' target=_blank style='color:#2F92EE;'>#肺水肿#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=181, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=82141, encryptionId=968a8214192, topicName=肺水肿)], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220519/c2ab253484ee4527a2d4e9589a4821ac/45de9bf494a54becb2ea4369c9d11e85.jpg, createdBy=7a3710, createdName=赛华佗, createdTime=Sun May 01 10:03:34 CST 2022, time=2022-05-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1295697, encodeId=d028129569e88, content=<a href='/topic/show?id=e02468846d4' target=_blank style='color:#2F92EE;'>#甘露醇#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=124, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=68846, encryptionId=e02468846d4, topicName=甘露醇)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f73a255, createdName=medscijoin, createdTime=Tue Apr 12 12:19:41 CST 2022, time=2022-04-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1333517, encodeId=31ce133351e19, content=<a href='/topic/show?id=4ce26423802' target=_blank style='color:#2F92EE;'>#水肿#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=184, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=64238, encryptionId=4ce26423802, topicName=水肿)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKCRibWHQArPHdSkqP90U1HwwqlGeU7BUgzY240D3v2ibBDJ09ybkGkwOjxz7qRmngZaGlK1taX6hfA/132, createdBy=2e772500094, createdName=小华子, createdTime=Tue Apr 12 12:19:41 CST 2022, time=2022-04-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1545130, encodeId=698c1545130a8, content=<a href='/topic/show?id=b7abe4635e0' target=_blank style='color:#2F92EE;'>#禁忌#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=343, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=74635, encryptionId=b7abe4635e0, topicName=禁忌)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=医者仁心, createdTime=Tue Apr 12 12:19:41 CST 2022, time=2022-04-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1210198, encodeId=c9091210198ee, content=学习了！, beContent=null, objectType=article, channel=null, level=null, likeNumber=126, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=2f802411854, createdName=1237a1fam90暂无昵称, createdTime=Mon Apr 11 08:41:54 CST 2022, time=2022-04-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1210170, encodeId=d5f712101e084, content=所以颈部脊髓损伤的病人一定要注意⚠️一进来就给开甘露醇消除水肿减轻压迫，但是一定要注意，颈部脊髓损伤的同时往往是由于强大的外力，这时候一定要考虑有没有颅内出血。, beContent=null, objectType=article, channel=null, level=null, likeNumber=138, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220411/bb3deb9d03ee4eafae8eba82376a59bd/e06eb11981e04597a064b4e5f134e69d.jpg, createdBy=96a66463151, createdName=ms2000002002500056, createdTime=Mon Apr 11 00:47:51 CST 2022, time=2022-04-11, status=1, ipAttribution=)]
    2022-04-11 1237a1fam90暂无昵称

    学习了！

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=1215986, encodeId=10dc1215986af, content=<a href='/topic/show?id=968a8214192' target=_blank style='color:#2F92EE;'>#肺水肿#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=181, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=82141, encryptionId=968a8214192, topicName=肺水肿)], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220519/c2ab253484ee4527a2d4e9589a4821ac/45de9bf494a54becb2ea4369c9d11e85.jpg, createdBy=7a3710, createdName=赛华佗, createdTime=Sun May 01 10:03:34 CST 2022, time=2022-05-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1295697, encodeId=d028129569e88, content=<a href='/topic/show?id=e02468846d4' target=_blank style='color:#2F92EE;'>#甘露醇#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=124, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=68846, encryptionId=e02468846d4, topicName=甘露醇)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f73a255, createdName=medscijoin, createdTime=Tue Apr 12 12:19:41 CST 2022, time=2022-04-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1333517, encodeId=31ce133351e19, content=<a href='/topic/show?id=4ce26423802' target=_blank style='color:#2F92EE;'>#水肿#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=184, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=64238, encryptionId=4ce26423802, topicName=水肿)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKCRibWHQArPHdSkqP90U1HwwqlGeU7BUgzY240D3v2ibBDJ09ybkGkwOjxz7qRmngZaGlK1taX6hfA/132, createdBy=2e772500094, createdName=小华子, createdTime=Tue Apr 12 12:19:41 CST 2022, time=2022-04-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1545130, encodeId=698c1545130a8, content=<a href='/topic/show?id=b7abe4635e0' target=_blank style='color:#2F92EE;'>#禁忌#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=343, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=74635, encryptionId=b7abe4635e0, topicName=禁忌)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=医者仁心, createdTime=Tue Apr 12 12:19:41 CST 2022, time=2022-04-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1210198, encodeId=c9091210198ee, content=学习了！, beContent=null, objectType=article, channel=null, level=null, likeNumber=126, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=2f802411854, createdName=1237a1fam90暂无昵称, createdTime=Mon Apr 11 08:41:54 CST 2022, time=2022-04-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1210170, encodeId=d5f712101e084, content=所以颈部脊髓损伤的病人一定要注意⚠️一进来就给开甘露醇消除水肿减轻压迫，但是一定要注意，颈部脊髓损伤的同时往往是由于强大的外力，这时候一定要考虑有没有颅内出血。, beContent=null, objectType=article, channel=null, level=null, likeNumber=138, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220411/bb3deb9d03ee4eafae8eba82376a59bd/e06eb11981e04597a064b4e5f134e69d.jpg, createdBy=96a66463151, createdName=ms2000002002500056, createdTime=Mon Apr 11 00:47:51 CST 2022, time=2022-04-11, status=1, ipAttribution=)]
    2022-04-11 ms2000002002500056

    所以颈部脊髓损伤的病人一定要注意⚠️一进来就给开甘露醇消除水肿减轻压迫，但是一定要注意，颈部脊髓损伤的同时往往是由于强大的外力，这时候一定要考虑有没有颅内出血。

    0