cfpdБюллетень физиологии и патологии дыханияBulletin Physiology and Pathology of Respiration1998-5029Дальневосточный научный центр физиологии и патологии дыхания10.36604/1998-5029-2020-78-161-177cfpd-848Research ArticleОБЗОРЫREVIEWSКоагулопатия при интоксикации родентицидами – антагонистами витамина КCoagulopathy at intoxication with rodenticides – antagonists of vitamin KВойцеховскийВ. В.VoytsekhovskiyV. V.

Валерий Владимирович Войцеховский, д-р мед. наук, доцент, зав. кафедрой госпитальной терапии с курсом фармакологии

675000, г. Благовещенск, ул. Горького, 95

Valeriy V. Voytsekhovskiy, MD, PhD, D.Sc. (Med.), Associate Professor, Head of Department of Hospital Therapy with Pharmacology Course 

95 Gor'kogo Str., Blagoveshchensk, 675000

voitsehovsckij@yandex.ruПивникА. В.PivnikA. V.

Александр Васильевич Пивник, д-р мед. наук, профессор, руководитель отдела онкогематологии и вторичных иммунодефицитных заболеваний

111123, г. Москва, Шоссе Энтузиастов, 86

Aleksandr V. Pivnik, MD, PhD, D.Sc. (Med.), Professor, Head of the Department of Oncohematology and Secondary Immunodeficiency Diseases 

86 Enthusiasts' Highway, Moscow, 111123

avpivnik@mail.ruФилатоваЕ. А.FilatovaE. A.

Екатерина Александровна Филатова, канд. мед. наук, врач гематологического отделения 

675028, г. Благовещенск, ул. Воронкова, 26

Ekaterina A. Filatova, MD, PhD (Med.), Hematologist 

26 Voronkova Str., Blagoveshchensk, 675028

ekaterina.gladun.86@mail.ruЕсенинаТ. В.ЕseninаT. V.

Татьяна Владимировна Есенина, врач-гематолог, заведующая гематологическим отделением

675028, г. Благовещенск, ул. Воронкова, 26

Tatiana V. Esenina, MD, Hematologist, Head of Department of Hematology 

26 Voronkova Str., Blagoveshchensk, 675028

gematology@bk.ruМишкуроваК. М.MishkurovaK. M.

Кристина Михайловна Мишкурова, врач гематологического отделения 

675028, г. Благовещенск, ул. Воронкова, 26

Kristina M. Mishkurova, MD, Hematologist 

26 Voronkova Str., Blagoveshchensk, 675028

mishkurova555@gmail.comФедороваН. А.FedorovaN. A.

Наталья Анатольевна Федорова, врач гематологического отделения

675028, г. Благовещенск, ул. Воронкова, 26

Natalia A. Fedorova, MD, Hematologist 

26 Voronkova Str., Blagoveshchensk, 675028

AOKB@amurzdrav.ruФедеральное государственное бюджетное образовательное учреждение высшего образования «Амурская государственная медицинская академия» Министерства здравоохранения Российской ФедерацииAmur State Medical AcademyГосударственное бюджетное учреждение здравоохранения «Московский клинический научный центр имени А.С.Логинова Департамента здравоохранения города Москвы»The Loginov Moscow Clinical Scientific CenterГосударственное автономное учреждение здравоохранения Амурской области «Амурская областная клиническая больница»Amur Regional Clinical Hospital202021122020078161177Copyright © Войцеховский В.В., Пивник А.В., Филатова Е.А., Есенина Т.В., Мишкурова К.М., Федорова Н.А., 20202020Войцеховский В.В., Пивник А.В., Филатова Е.А., Есенина Т.В., Мишкурова К.М., Федорова Н.А.Voytsekhovskiy V.V., Pivnik A.V., Filatova E.A., Еseninа T.V., Mishkurova K.M., Fedorova N.A.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://cfpd.elpub.ru/jour/article/view/848

Обзор литературы посвящен отравлениям родентицидами (РДЦ), содержащими непрямые антикоагулянты – антагонисты витамина К (АВК). В работе охарактеризованы основные группы антикоагулянтов, которые используются в таких препаратах, описан механизм их действия. Авторы провели анализ значительного количества зарубежных и отечественных литературных источников по отравлению РДЦ данной группы. Сделано заключение, что интоксикация АВК встречаются гораздо реже, чем другими РДЦ: в основном это случайный прием препаратов, большинство пострадавших – дети. Употребление РДЦ-АВК психиатрическими пациентами и криминальные случаи встречаются нечасто. Анализ литературы показал, что подавляющее число отравлений происходит при употреблении АВК, которые содержатся в готовых приманках для борьбы с грызунами, доступных большинству населения. Интоксикация современными РДЦ-АВК – суперварфаринами возможна при пероральном, дермальном воздействии и попадании на слизистые оболочки глаза, они обладают кумулятивным действием. Основное клиническое проявление отравления суперварфаринами – геморрагический синдром. Клинические признаки коагулопатии бывают гораздо более выражены при преднамеренном отравлении, чем при случайном, поскольку для появления геморрагического синдрома необходим прием большого количества вещества, содержащегося в готовой приманке. Описаны принципы и особенности диагностики, дифференциальной диагностики и лечения коагулопатии данного генеза. У всех пациентов отмечаются изменения в коагулограмме, характерные для витамин К-зависимой коагулопатии: увеличение международного нормированного отношения, протромбинового времени и активированного частичного тромбопластинового времени, снижение уровней II, VII, IX и X факторов свертывания крови, физиологических антикоагулянтов – протеинов С и S. Определить содержание суперварфарина в крови с помощью высокоэффективной жидкостной хроматографии возможно далеко не в каждом лечебном учреждении. При клинической диагностике коагулопатии и выявлении в коагулограмме изменений, характерных для дефицита витамина К, даже если не установлена его этиологическая причина, сразу необходимо назначение адекватной терапии: введение свежезамороженной плазмы и/или концентратов факторов протромбинового комплекса, назначение препаратов витамина К, симптоматическая терапия. С учетом большого периода полужизни суперварфаринов, коагулопатия может персистировать несколько месяцев, в течение которых необходимо продолжать лечение. При своевременной диагностике и назначении адекватной терапии прогноз в большинстве случаев благоприятный. Смертность среди людей при отравлении суперварфаринами не высокая. В качестве иллюстрации авторы приводят два клинических случая из личной практики.

The review is devoted to poisoning with rodenticides containing indirect anticoagulants – vitamin K antagonists (VKA). The work describes the main groups of anticoagulants that are used in such preparations, describes the mechanism of their action. The authors analyzed a significant number of foreign and local literary sources on the poisoning of the rodenticides of this group. It was concluded that VKA intoxication occurs much less frequently than other rodenticides; it is mainly the occasional intake of drugs, most of the victims are children. The use of rodenticides-VKA by psychiatric patients and criminal cases are not common. Analysis of the literature has shown that the overwhelming number of poisonings occurs when using VKA, which are contained in ready-made rodent-control baits available to the majority of the population. Intoxication with modern rodenticides-VKA – superwarfarins is possible with oral, dermal exposure and contact with the mucous membranes of the eye; they have a cumulative effect. The main clinical manifestation of superwarfarin poisoning is hemorrhagic syndrome. The clinical signs of coagulopathy are much more pronounced in case of deliberate poisoning than in case of accidental poisoning, since for the appearance of hemorrhagic syndrome, a large amount of the substance contained in the finished bait is required. The principles and features of diagnosis, differential diagnosis and treatment of coagulopathy of this genesis are described. All patients have changes in the coagulogram, characteristic of vitamin K-dependent coagulopathy: an increase in the international normalized ratio, prothrombin time and activated partial thromboplastin time, a decrease in the levels of II, VII, IX and X blood coagulation factors, physiological anticoagulants – proteins C and S. Determine the concentration of superwarfarin in the blood using high performance liquid chromatography is not possible in every medical institution. In the clinical diagnosis of coagulopathy and the identification in the coagulogram of changes characteristic of vitamin K deficiency, even if its etiological cause has not been established, it is immediately necessary to prescribe adequate therapy: the introduction of fresh frozen plasma and/or concentrates of prothrombin complex factors, prescription of vitamin K preparations, symptomatic therapy. Taking into consideration the long half-life of superwarfarins, coagulopathy can persist for several months, during which treatment should be continued. With timely diagnosis and the appointment of adequate therapy, the prognosis in most cases is favorable. The mortality rate among people with superwarfarin poisoning is not high. As an illustration, the authors cite two clinical cases from personal practice.

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The authors declare that there are no conflicts of interest present.