URG-L: RE : URG-L: acetyl cysteine et injection de produit de contraste

[Pierre Baril]

Clinical evidence d�cembre 2001   We found no evidence that adenosine antagonists are effective in preventing ARF.   Benefits: We found one systematic review (3 RCTs, 177 people) of theophylline, a non-selective adenosine antagonist, for prevention of ARF induced by contrast media. [31] It found that theophylline provided no protection against ARF when people are adequately hydrated. We found no RCTs evaluating selective adenosine antagonists or non-selective adenosine antagonists for other forms of ARF.   Harms: Theophylline has a narrow therapeutic index and known adverse effects (see harms of theophyllines under chronic obstuctive pulomonary disease).   Comment: None.   OPTION    Acetylcysteine   We found insufficient evidence to evaluate the effectiveness of acetylcysteine in the prevention of ARF due to exposure to contrast media or other aetiologies.   Benefits: We found one small, low-powered RCT (83 people with chronic renal insufficiency) examining the effect of acetylcysteine on the prevention of ARF induced by contrast media. [33] It found that the incidence of ARF (defined as an increase in serum creatinine > 0.5 mg/dl or 44 �mol/l at 48 h) was significantly reduced (AR 1/41 [2%] with acetylcysteine v 9/42 [21%] with placebo; RR 0.11, 95% CI 0.02 to 0.86; NNT 6, 95% CI 3 to 21).   Harms: Acetylcysteine has been widely used to treat people with acetaminophen overdose, and has virtually no toxicity at therapeutic levels (see harms under paracetamol [acetaminophen] poisoning).   Comment: The clinical relevance of a rise in serum creatinine of 0.5 mg/dl at 48 hours, the study end point, is unclear. Long term follow up was not done and the study was far too small to evaluate either dialysis or mortality as end points     -----Message d'origine-----   pas EBM non plus mais apres analyse de l article et discussion avec nos nephrologues le serum physiologique fait aussi bien.... on n' a donc pas retenu ce traitement � l'urgence  Qui utilise le th�ophylline dans la m�me indication? ___________________________   Dr Patrick Miroux   SAU - D�pt. de M�decine d'Urgence  80054  CHU Amiens nord cedex 1   fax:0322668389   tel: 0322668000   Mailto:[EMAIL PROTECTED]   Mailto:[EMAIL PROTECTED] ________________________________ > -----Message d'origine----- > De:   Pierre Marie ROY [SMTP:[EMAIL PROTECTED]] > Date: mercredi 13 mars 2002 09:18 > �:    [EMAIL PROTECTED] > Objet:        URG-L: acetyl cysteine et injection de produit de contraste > > Nous l'utilisons mais sans pouvoir v�ritablement en appr�cier > l'efficacit�. > > Quelques difficult�s li�es au protocole du papier, la NAC devrait �tre > d�but�e la veille ce qui n'est pas tout � fait adapt� � des proc�dures > d'urgence. En pratique cela m'est arriv� de faire un protocole utilisant > la NAC IV d�but�e quelques heures avant le geste avec un protocole > identique � celui des intox au parac�tamol... bien sur, on est loin de > l'EBM ! : > > Study Protocol > > The patients were randomly assigned to receive either the antioxidant > acetylcysteine and intravenous saline before and after administration of > the contrast agent (acetylcysteine group) or placebo and saline (control > group). Acetylcysteine was given orally at a dose of 600 mg twice daily, > on the day before and on the day of administration of the contrast agent, > for a total of two days. Saline (0.45 percent) was given intravenously at > a rate of 1 ml per kilogram of body weight per hour for 12 hours before > and 12 hours after administration of the contrast agent. All patients were > encouraged to drink if they were thirsty. > > > Petite note aussi, le papier a montr� que les patients sous NAC + s�rum > sal�) avait une cr�atinine qui diminuait alors que les autres (placebo+ > s�rum sal�) avait une cr�atinine qui montait mais aucun n'a eu besoin > d'une dialyse : The mean serum creatinine concentration for all patients > was 2.4�1.3 mg per deciliter (216�116 �mol per liter). In the control > group, the mean serum creatinine concentration increased from 2.4�1.3 to > 2.6� 1.5 mg per deciliter (212�114 to 226�133 �mol per liter) 48 hours > after administration of the contrast agent (P=0.18) ( Figure 1 > <http://content.nejm.org/cgi/content/full/343/3/180?ijkey=NP7DKZmHHGOOY# F1 > >). In the acetylcysteine group, the mean serum creatinine concentration > decreased from 2.5�1.3 to 2.1�1.3 mg per deciliter (220�118 to 186�112 > �mol per liter) 48 hours after administration of the contrast agent > (P<0.001). The absolute change in serum creatinine concentration was > significantly greater in the control group than in the acetylcysteine > group (P<0.001). > > A vous lire > > > PMR > >       -----Message d'origine----- >       De : taboulet < [EMAIL PROTECTED] > <mailto:[EMAIL PROTECTED]>> >       � : URG-L Mailing List < [EMAIL PROTECTED] > <mailto:[EMAIL PROTECTED]>> >       Date : mardi, mars 12, 2002 21:40 >       Objet : URG-L: acetyl cysteine et injection de produit de contraste > > >       Les injections de produit de contraste sont d�l�t�res sur rein > malade. >       Mais voil� une publication (du NEJM 2000) qui devrait nous faciliter > la >       vie. Une simple administration per os (600 mg orally twice daily) >       pr�viendrait la n�phrotoxicit� r�nale des  produits de contraste >       utilis�s par les radiologues. Je n'arrive pas � comprendre pourquoi > les >       radiologues et les n�phrologues ne sont pas venus nous en parler > plus >       t�t. Des info l� dessus ? Moi j'ai commenc� mais je manque de recul. > PT > > -- Axel Ellrodt Essonne, France http://zzorglub.ifrance.com/ A website for emergency physicians Azee'iil'inaa biwebsite Lomana uebio nan partonagjatri Honlap oxyologusok szamara