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甘露醇治疗的并发症

Author
Richard H Sterns, MD
Section Editor
Michael Emmett, MD
Deputy Editor
John P Forman, MD, MSc
Translators
王婉宁, 主治医师

引言

甘露醇作为一种高渗溶液，主要用于治疗脑水肿和青光眼。尽管患者一般耐受良好，但如果没有对患者进行密切监测，则可发生多种液体、电解质和肾脏并发症。 (参见“成人颅内压升高的评估与处理”，关于‘甘露醇’一节和“闭角型青光眼”，关于‘治疗’一节)

并发症

容量不足和高钠血症 — 甘露醇可通过肾小球自由滤过，而不被肾小管重吸收。因此，其充当了一种渗透性利尿剂，增加尿中钠和无电解质水的丢失。不对液体丢失进行相应补充可导致可以很严重的容量不足及高钠血症[1]。

容量扩增、低钠血症、高钾血症、低钾血症和代谢性酸中毒 — 如果输注非常高剂量的高渗性甘露醇或者如果在已有肾衰竭的患者中应用该药，那么甘露醇会滞留于循环中[2-4]。接下来发生的血浆渗透压增高(类似于高血糖所产生的那样)可导致水和钾渗透性地移出细胞，从而导致细胞外液容量扩增(并可能导致肺水肿)、低钠血症、代谢性酸中毒(通过稀释作用)及高钾血症[5]。脑细胞失水可导致神经系统症状。不伴神经系统症状的容量扩增和稀释性低钠血症，也可在经尿道切除前列腺或膀胱期间应用等渗性甘露醇作为冲洗液时被诱发。 (参见“经尿道切除术或宫腔镜操作后的低钠血症”)

高渗性甘露醇使用后血浆钾浓度升高是由钾移出细胞进入细胞外液所致，这种移动经由以下两种机制：(1)失水诱导的细胞内钾浓度升高促使钾被动性通过细胞膜上的钾通道移出；(2)溶剂(水)和溶质间摩擦力可导致钾通过细胞膜上水孔隙被运送出去(此过程称为溶剂拖拽)。相似的过程可出现于急性高钠血症时[6]，也是未控制的糖尿病患者出现显著高血糖时常伴有高钾血症的主要原因[7,8]。 (参见“成人糖尿病酮症酸中毒和高渗性高血糖状态的临床特点和诊断”)

如果肾功能正常，那么甘露醇所致短暂性钾移出细胞外很少导致高钾血症。一项研究包括45例因神经外科病况而应用甘露醇(平均剂量为一次28g，每6小时1次)治疗数日的患者，研究发现第1日仅1例(2.4%)患者的血清钾大于5.5meq/L，随后几日没有患者出现高钾血症[9]。相较之下，22%的患者在第1日发生低钾血症(血清钾水平＜3.5meq/L)，到第3日时这一比例增加至52%。

   

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Literature review current through: 2017-06 . | This topic last updated: 2016-10-19.
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