Digoksin Zehirlenmesinde Yoğun Bakım Yönetimi
Özet
Digoksin, kalp yetmezliği ve atriyal fibrilasyon tedavisinde kullanılan dar terapötik indekse sahip bir kardiyak glikozittir. Özellikle ileri yaş, böbrek yetmezliği ve elektrolit dengesizlikleri olan hastalarda toksisite riski artmaktadır. Digoksin zehirlenmesi; bradikardi, iletim bozuklukları, ventriküler aritmiler, gastrointestinal ve nörolojik semptomlarla seyredebilir ve mortal sonuçlara yol açabilir. Bu bölümde digoksinin farmakokinetik özellikleri, toksisite mekanizmaları, klinik bulguları, EKG değişiklikleri ve güncel tedavi yaklaşımları ayrıntılı olarak ele alınmaktadır. Ayrıca ileri yaş, kronik böbrek hastalığı ve sepsis eşlik eden bir olgu üzerinden yoğun bakım yönetimi tartışılmaktadır. Tedavi yaklaşımında ilacın kesilmesi, elektrolit düzeltilmesi, semptomatik destek, geçici pacemaker uygulaması ve gerekli durumlarda digoksin immün Fab kullanımı yer almaktadır. Yüksek riskli hastalarda doz ayarlaması ve yakın serum düzeyi takibi mortaliteyi azaltmada kritik öneme sahiptir.
Digoxin is a cardiac glycoside with a narrow therapeutic index, commonly used in heart failure and atrial fibrillation. The risk of toxicity increases particularly in elderly patients, those with renal impairment, and individuals with electrolyte disturbances. Digoxin intoxication may present with bradycardia, conduction abnormalities, ventricular arrhythmias, and gastrointestinal or neurological symptoms, potentially leading to fatal outcomes.This chapter reviews the pharmacokinetic properties of digoxin, mechanisms of toxicity, clinical manifestations, characteristic ECG findings, and current treatment strategies. A case involving an elderly patient with chronic kidney disease and sepsis is presented to illustrate intensive care management principles.Treatment includes discontinuation of digoxin, correction of electrolyte imbalances, supportive care, temporary pacing when indicated, and administration of digoxin-specific antibody fragments (digoxin immune Fab) in life-threatening cases. Dose adjustment and close therapeutic drug monitoring are essential in high-risk patients to reduce morbidity and mortality.
Referanslar
Grubb A, Mentz RJ. Pharmacological management of atrial fibrillation in patients with heart failure with reduced ejection fraction: review of current knowledge and future directions. Expert Rev Cardiovasc Ther. 2020 Feb;18(2):85-101.
Ren Y, Ribas HT, Heath K, Wu S, Ren J, Shriwas P, Chen X, Johnson ME, Cheng X, Burdette JE, Kinghorn AD. Na+/K+-ATPase-Targeted Cytotoxicity of (+)-Digoxin and Several Semisynthetic Derivatives. J Nat Prod. 2020 Mar 27;83(3):638-648.
Lunney M, Ruospo M, Natale P, Quinn RR, Ronksley PE, Konstantinidis I, Palmer SC, Tonelli M, Strippoli GF, Ravani P. Pharmacological interventions for heart failure in people with chronic kidney disease. Cochrane Database Syst Rev. 2020 Feb 27;2(2):CD012466.
Writing Committee Members; ACC/AHA Joint Committee Members. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Card Fail. 2022 May;28(5):e1-e167
Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR., Peer Review Committee Members. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024 Jan 02;149(1):e1-e156.
Bromley HL, Dave R, Lord N, Wright P, Rowland M, Gandhi A. Gynaecomastia: when and why to refer to specialist care. Br J Gen Pract. 2021 Apr;71(705):185-188.
Fu JL, Yu Q, Li MD, Hu CM, Shi G. Deleterious cardiovascular effect of exosome in digitalis-treated decompensated congestive heart failure. J Biochem Mol Toxicol. 2020 May;34(5):e22462.
Angraal S, Nuti SV, Masoudi FA, Freeman JV, Murugiah K, Shah ND, Desai NR, Ranasinghe I, Wang Y, Krumholz HM. Digoxin Use and Associated Adverse Events Among Older Adults. Am J Med. 2019 Oct;132(10):1191-1198.
Gona SR, Rosenberg J, Fyffe-Freil RC, Kozakiewicz JM, Money ME. Review: Failure of current digoxin monitoring for toxicity: new monitoring recommendations to maintain therapeutic levels for efficacy. Front Cardiovasc Med. 2023;10:1179892.
Negroni MS, Marengo A, Caruso D, Tayar A, Rubiolo P, Giavarini F, Persampieri S, Sangiovanni E, Davanzo F, Carugo S, Colombo ML, Dell'Agli M. A Case Report of Accidental Intoxication following Ingestion of Foxglove Confused with Borage: High Digoxinemia without Major Complications. Case Rep Cardiol. 2019;2019:9707428.
