Risk Prediction Of Neuropsychiatric Sequelae From Acute Carbon Monoxide Poisoning And Evaluation Of Efficacy And Safety Of Interventions (Hyperbaric Oxygen,Glucocorticoid,Butylphthalide)

Carbon monoxide(CO)is often poisoned by excessive inhalation because it is colorless,odorless and tasteless.Acute carbon monoxide poisoning(ACOP)is a common clinical emergency.The toxic manifestations are multiple organ lesions,and the mainly one is brain injury.Despite appropriate treatment,there are still a small number of patients with neuropsychiatric sequelae(NS).According to whether there is a false recovery period,it can be clinically considered as persistent neuropsychiatric sequelae(PNS)and delayed neuropsychiatric sequelae(DNS),also known as delayed encephalopathy after carbon monoxide poisoning(DEACMP).The disability rate of NS is high,and its main clinical manifestations are mental retardation,abnormal mental behavior,dyskinesia and fecal incontinence.Therefore,it is necessary to explore some simple and easily available NS risk prediction factors.Carboxyhemoglobin(COHb)formed by the combination of CO and hemoglobin can cause the binding disorder of oxygen and hemoglobin,and lead to hypoxia of tissues and organs of the body.This is the classical theory of the pathogenesis of CO poisoning.Pathogenesis is the target and basis of treatment.Hyperbaric oxygen is regarded as the "golden means" for treating acute CO poisoning because it can promote the dissociation of COHb and accelerate the removal of CO.With the passage of time,some advances have been made in the study of the mechanism of CO poisoning.Many theories have been put forward,such as the mechanism of inflammation and immune damage,oxidative stress and cell death.Therefore,there is controversy about hyperbaric oxygen treatment for acute CO poisoning at home and abroad.Currently,most studies on the treatment of neurological and psychiatric sequelae of CO poisoning focus on DNS(DEACMP).There are few studies on DNS at home and abroad.Domestic clinical guidelines for the treatment of carbon monoxide poisoning suggest that hyperbaric oxygen should be used as a treatment for DNS,but there is no evidence-based medical evidence that glucocorticoids can significantly improve the prognosis of DNS patients.DNS is caused by central nervous system injury.Restoring the function of the central nervous system may be a potential treatment for DNS.Butylphthalide is a fat-soluble drug with good blood-brain barrier permeability.At present,clinical studies have shown that butylphthalide can promote the recovery of daily living ability and neurological function in DNS patients,but there are few evidence-based evidence at home and abroad.This topic will study the risk prediction factors and intervention measures of neurological and psychiatric sequelae of CO poisoning.On the one hand,through the analysis of the relationship between the clinical characteristics of ACOP patients and the main inflammation indexes in blood routine and the neurological and psychiatric sequelae of CO poisoning,to explore the gender differences and find out the higher value risk predictors;on the other hand,through meta-analysis,to study the neurological sequelae and all-cause mortality of patients with carbon monoxide poisoning caused by hyperbaric oxygen.To explore the efficacy and safety of glucocorticoid combined with hyperbaric oxygen and butylphthalide in the treatment of delayed encephalopathy caused by acute carbon monoxide poisoning.The first part is about the predictive value and gender differences of neutrophil/platelet ratio for neuropsychiatric sequelae of acute carbon monoxide poisoning.A total of 265 ACOP patients were selected from January 2008 to December 2017.Patients were divided into NS group(n=23)and non-NS group(n=242)according to the presence or absence of NS within 2 months after ACOP.The clinical characteristics and inflammatory markers in blood routine were compared between the two groups,and further subgroup analysis was made according to different gender.To evaluate the predictive value of each index for NS in ACOP patients,and draw the receiver operating characteristic(ROC)curve.The results showed that the age of NS group was significantly higher than that of non-NS group(P < 0.05),while the Glasgow coma score(GCS)of NS group was significantly lower than that of non-NS group(P< 0.05).Multivariate analysis showed that age and GCS at admission were independent risk factors for NS in ACOP patients.Subgroup analysis showed that there were significant differences in neutrophil count(NEUT),platelet(PLT)and neutrophil/platelet ratio(NPR)between different genders in NS group(P< 0.05).NPR combined with age and GCS at admission predicted that the area under ROC curve of male ACOP patients with NS was 0.936(95% CI 0.855-0.923;P = 0.000).The second part,the effects of hyperbaric oxygen on neurological sequelae and all-cause mortality in patients with carbon monoxide poisoning: Meta-analysis of randomized controlled trials.Computer search selected randomized controlled trials of hyperbaric oxygen therapy for acute carbon monoxide poisoning from the establishment of electronic databases(Pub Med,CNKI,EMBase,The Cochrane Library,VIP,Wed of Science CBM and Wanfang Data)to March 1,2019.Random effect model was used to calculate the relative risk(RR)and weighted mean deviation(WMD)of the results and the corresponding 95% confidence interval(CI).Publication bias,sensitivity and subgroup analysis were performed.Seven randomized controlled trials were included,including nine cohorts and 2023 patients with carbon monoxide poisoning.The results showed that HBO treatment was associated with a lower risk of memory impairment compared with patients receiving normal oxygen(NBO).The effect of 2 sessions of HBO on memory impairment may be lessThe third part,glucocorticoid treatment of acute carbon monoxide poisoning delayed encephalopathy efficacy and safety analysis.Pub Med,CNKI,EMBase,The Cochrane Library,VIP,Wed of Science CBM and Wanfang Data are searched by computer.To collect randomized controlled trials of glucocorticoids in the treatment of delayed encephalopathy after carbon monoxide poisoning,and to search the self-established database as of January 31,2019.After literature screening,data extraction and quality evaluation,the total effective rate,recovery rate,inefficiency,MMSE,Barthel index(BI)score and other indicators were analyzed,and the meta-analysis was carried out with Rev Man 5.3 software.Results: A total of 10 RCTs were included in this study,involving 660 patients with DNS,330 in the glucocorticoid group and 330 in the control group.Meta-analysis results: The total effective rate of the experimental group was higher than that of the control group [RR = 1.27,95% CI(1.17,1.37),P< 0.00001];the cure rate of the experimental group was higher than that of the control group [RR = 1.55,95% CI(1.22,1.96),P= 0.0003];the inefficiency of the controll group was higher than that of the experimental group [RR = 0.26,95% CI(0.16,0.42),P < 0.00001];and the MMSE score was improved.Compared with the control group [WMD = 5.35,95% CI(4.07,6.64),P < 0.00001],the experimental group was superior to the control group in improving BI score [WMD = 15.02,95% CI(3.17,26.86),P= 0.01].The adverse reactions of glucocorticoids were less.All adverse events returned to normal within one week after withdrawal of drugs,and no special treatment was needed.The fourth part,analysis of efficacy and safety of butylphthalide in treating delayed encephalopathy caused by acute carbon monoxide poisoning.Computer searches Pub Med,CNKI,EMBase,The Cochrane Library,VIP,Wed of Science CBM and Wan Fang Data.To collect the randomized controlled trials of butylphthalide in the treatment of delayed encephalopathy after carbon monoxide poisoning,and to search the self-established database until January 31,2019.After literature screening,data extraction and quality evaluation,the total effective rate,MMSE,BI score and other indicators were collected and analyzed by Rev Man 5.3 software.Results Twelve RCTs were included in this study,involving 888 DNS patients,447 in the butylphthalide group and 441 in the control group.Meta analysis showed that the total effective rate of butylphthalide group was higher than that of control group [RR = 3.73,95%CI(2.54,5.48),P<0.00001];the improvement of MMSE score of butylphthalide group was better than that of control group [WMD=4.85,95%CI(2.76,6.94),P<0.00001];the improvement of BI score of butylphthalide group was better than that of control group[WMD = 10.99,95%CI(6.78,15.20),P < 0.00001].There were no obvious adverse reactions in butylphthalide group.The results of the above research can draw the following conclusions:1.NPR is a predictor of NS in male ACOP patients,and GCS combined with age and admission can improve its predictive value.2.Compared with NBO,HBO treatment can significantly reduce the risk of memory impairment.However,the effect of HBO twice a day on memory impairment may not be as effective as that of HBO once a day.3.On the basis of hyperbaric oxygen therapy,the effect of glucocorticoid on DNS is better than that of hyperbaric oxygen alone,and it has good safety.4.On the basis of hyperbaric oxygen therapy,the effect of NBP on DNS is better than that of hyperbaric oxygen alone,and it has good safety.