{"id":11385520,"date":"2012-07-15T00:00:00","date_gmt":"2012-07-14T22:00:00","guid":{"rendered":"https:\/\/alertdiver.eu\/uncategorized-cs_cz\/dekompresni-onemocneni-u-potapece-vegetariana\/"},"modified":"2012-07-15T00:00:00","modified_gmt":"2012-07-14T22:00:00","slug":"dekompresni-onemocneni-u-potapece-vegetariana","status":"publish","type":"post","link":"https:\/\/alertdiver.eu\/cs_CZ\/clanky\/dekompresni-onemocneni-u-potapece-vegetariana\/","title":{"rendered":"Dekompresn\u00ed onemocn\u011bn\u00ed u pot\u00e1p\u011b\u010de vegetari\u00e1na"},"content":{"rendered":"

(Pozn\u00e1mka vydavatele: Uv\u00e1d\u00edme zkr\u00e1cenou verzi \u010dl\u00e1nku Dekompresn\u00ed onemocn\u011bn\u00ed u pot\u00e1p\u011b\u010de vegetari\u00e1na. Hroz\u00ed vegetari\u00e1nsk\u00fdm pot\u00e1p\u011b\u010d\u016fm v\u011bt\u0161\u00ed riziko? Tato p\u0159\u00edpadov\u00e1 studie byla zve\u0159ejn\u011bna v “Caisson”, 26. ro\u010dn\u00edk \/ \u010d. 2, str. 24-27)
<\/em><\/p>\n

\u0160estat\u0159icetilet\u00fd b\u011blo\u0161sk\u00fd instruktor pot\u00e1p\u011bn\u00ed provedl jeden ponor o d\u00e9lce 60 minut do hloubky 18 metr\u016f a druh\u00fd po dvouhodinov\u00e9m odpo\u010dinku na hladin\u011b do maxim\u00e1ln\u00ed hloubky 21 metr\u016f na dobu 52 minut. V jeho pot\u00e1p\u011b\u010dsk\u00e9m po\u010d\u00edta\u010di byla napl\u00e1novan\u00e1 dekompresn\u00ed p\u0159est\u00e1vka o d\u00e9lce 8 minut v hloubce 3 metr\u016f, kterou tento pot\u00e1p\u011b\u010d tak\u00e9 dodr\u017eel.<\/p>\n

Asi 45 minut po druh\u00e9m ponoru za\u010dal poci\u0165ovat brn\u011bn\u00ed v noh\u00e1ch a v lev\u00e9 ruce, bolest v lokti lev\u00e9 pa\u017ee a silnou \u00fanavu. B\u011bhem p\u0159evozu do hyperbarick\u00e9 komory d\u00fdchal stoprocentn\u00ed kysl\u00edk a rehydroval se vypit\u00edm 500 ml vody.<\/p>\n

P\u0159i p\u0159\u00edjezdu do hyperbarick\u00e9 komory o 6 hodin pozd\u011bji se dob\u0159e orientoval, mluvil norm\u00e1ln\u011b, m\u011bl norm\u00e1ln\u00ed reakci zorni\u010dek a p\u0159i kardiopulmon\u00e1rn\u00edm vy\u0161et\u0159en\u00ed se nezjistilo nic zvl\u00e1\u0161tn\u00edho. V\u00fdsledek vy\u0161et\u0159en\u00ed hlavov\u00fdch nerv\u016f byl norm\u00e1ln\u00ed, ale pot\u00e1p\u011b\u010d prokazoval slab\u00e9 reflexy u obou pa\u017e\u00ed, nohy nevykazovaly \u017e\u00e1dn\u00fd reflex, nicm\u00e9n\u011b s\u00edla pa\u017e\u00ed i nohou byla norm\u00e1ln\u00ed, abnorm\u00e1ln\u00ed v\u00fdsledky v\u0161ak uk\u00e1zalo vy\u0161et\u0159en\u00ed vibra\u010dn\u00edho \u010dit\u00ed a propriocepce v noh\u00e1ch. (Propriocepce je schopnost nervov\u00e9ho syst\u00e9mu zaznamenat zm\u011bny vznikaj\u00edc\u00ed ve svalech a uvnit\u0159 t\u011bla pohybem a svalovou \u010dinnost\u00ed, tzv. “polohocit”). Koordinace byla norm\u00e1ln\u00ed.<\/p>\n

Pacient byl l\u00e9\u010den podle tabulky 6 N\u00e1mo\u0159nictva Spojen\u00fdch st\u00e1t\u016f a dostalo se mu 4 denn\u00edch sezen\u00ed v hyperbarick\u00e9 komo\u0159e s O2 (2,4 bar, 90 min). B\u011bhem l\u00e9\u010dby podle zm\u00edn\u011bn\u00e9 tabulky se jeho p\u0159\u00edznaky postupn\u011b zlep\u0161ovaly, ale o p\u0159est\u00e1vk\u00e1ch mezi pobyty v komo\u0159e se senzorick\u00e9 v\u00fdpadky vracely a opakovan\u011b se dostavovala slabost hlavn\u011b v doln\u00edch \u010d\u00e1stech nohou. \u010ctvrt\u00fd den jeho l\u00e9\u010dby jsme se dozv\u011bd\u011bli o jeho vegetari\u00e1nsk\u00e9 v\u00fd\u017eiv\u011b, proto byly provedeny dodate\u010dn\u00e9 hematologick\u00e9 testy, p\u0159i kter\u00fdch se zjistily abnorm\u00e1n\u00ed hodnoty nazna\u010duj\u00edc\u00ed makrocyt\u00e1rn\u00ed an\u00e9mii s koncentrac\u00ed vitam\u00ednu B12 na \u00farovni 100 pmol\/l (norm\u00e1ln\u00ed rozmez\u00ed je 165-835), kyseliny listov\u00e9 10,9 nmol (9.2-38), procentem saturace \u017eeleza ve v\u00fd\u0161i 7% (25-50), s\u00e9rov\u00e9ho \u017eeleza 4 μmol\/l (12-30) a ferritinu 108 μg\/l (50-300). Schilling\u016fv test neprok\u00e1zal malabsorpci.<\/p>\n

Pacient dost\u00e1val denn\u011b intramuskul\u00e1rn\u011b 1000 μg cyanocobalaminu po dobu 5 dn\u016f, potom tot\u00e9\u017e jednou t\u00fddn\u011b b\u011bhem prvn\u00edho m\u011bs\u00edce a jednou m\u011bs\u00ed\u010dn\u011b po dobu dal\u0161\u00edch 3 m\u011bs\u00edc\u016f. Zcela se uzdravil b\u011bhem 4 t\u00fddn\u016f a byly mu p\u0159edeps\u00e1ny multivitaminov\u00e9 tablety obsahuj\u00edc\u00ed i B12. Vzhledem k jeho zam\u011bstn\u00e1n\u00ed (instruktor sportovn\u00edho pot\u00e1p\u011bn\u00ed) jsme jej vy\u0161et\u0159ili na p\u0159\u00edtomnost patentn\u00edho foramen ovale (PFO – mal\u00fd otvor v srde\u010dn\u00ed p\u0159ep\u00e1\u017ece s\u00edn\u00ed jako poz\u016fstatek embryon\u00e1ln\u00edho ob\u011bhu) pomoc\u00ed transezofage\u00e1ln\u00ed echokardiografie. Zde byl v\u00fdsledek vy\u0161et\u0159en\u00ed bez n\u00e1lezu. Jeho krevn\u00ed hodnoty se vr\u00e1tily do norm\u00e1lu po 4 m\u011bs\u00edc\u00edch a po 6 m\u011bs\u00edc\u00edch se vr\u00e1til k pot\u00e1p\u011bn\u00ed.<\/p>\n

Diskuse<\/strong><\/p>\n

Po prostudov\u00e1n\u00ed p\u0159\u00edslu\u0161n\u00e9 l\u00e9ka\u0159sk\u00e9 literatury jsme dosp\u011bli k n\u00e1zoru, \u017ee se jedn\u00e1 o prvn\u00ed publikovan\u00fd p\u0159\u00edpad pot\u00e1p\u011b\u010de s DSC, kter\u00fd v d\u016fsledku vegetari\u00e1nstv\u00ed trp\u011bl nedostate\u010dnost\u00ed vitam\u00ednu B12.<\/p>\n

Vitam\u00edn B12 (cyanocobalamin) je hojn\u011b obsa\u017een v mase, ryb\u00e1ch a ve v\u011bt\u0161in\u011b vedlej\u0161\u00edch produkt\u016f \u017eivo\u010di\u0161n\u00e9ho p\u016fvodu. Jeho klinick\u00fd nedostatek se objevuje i u p\u0159\u00edsn\u00fdch vegetari\u00e1n\u016f pom\u011brn\u011b z\u0159\u00eddka, nebo\u0165 denn\u011b je jej pot\u0159eba pouze 2.0 – 5.0 mcg a tento vitam\u00edn je dostate\u010dn\u011b zastoupen i v lu\u0161t\u011bnin\u00e1ch. Nej\u010dast\u011bj\u0161\u00ed p\u0159\u00ed\u010dinou nedostatku B12 je malabsorpce z d\u016fvodu posti\u017een\u00ed endogenn\u00ed produkce intrinsick\u00e9ho faktoru.<\/p>\n

Nedostate\u010dnost vitam\u00ednu B12 negativn\u011b ovliv\u0148uje m\u00edchu, mozek, o\u010dn\u00ed nervy a perifern\u00ed nervovou soustavu. P\u0159\u00edznaky se objevuj\u00ed postupn\u011b a za\u010d\u00ednaj\u00ed v\u0161eobecnou slabost\u00ed prov\u00e1zenou pocity brn\u011bn\u00ed a mraven\u010den\u00ed. Postupn\u011b se k tomu p\u0159id\u00e1v\u00e1 nejist\u00e1 ch\u016fze a ztrnulost a slabost kloub\u016f (hlavn\u011b u nohou). Z po\u010d\u00e1tku nemus\u00ed j\u00edt o \u017e\u00e1dn\u00e9 objektivn\u00ed p\u0159\u00edznaky, ale pozd\u011bj\u0161\u00ed vy\u0161et\u0159en\u00ed odhaluj\u00ed poruchu zadn\u00edch a postrann\u00edch sloupc\u016f m\u00edchy. K nejobvyklej\u0161\u00edm pr\u016fvodn\u00edm jev\u016fm pat\u0159\u00ed ztr\u00e1ta vibra\u010dn\u00edho \u010dit\u00ed v noh\u00e1ch i v oblasti trupu a zhor\u0161en\u00e9 polohov\u00e9 \u010dit\u00ed. Nav\u00edc doch\u00e1z\u00ed ke ztr\u00e1t\u011b s\u00edly, ke zm\u011bn\u00e1m \u0161lachov\u00fdch reflex\u016f a ke \u0161kubav\u00fdm k\u0159e\u010d\u00edm nohou.<\/p>\n

U pot\u00e1p\u011b\u010d\u016f za\u010d\u00edn\u00e1 akutn\u00ed m\u00ed\u0161n\u00ed DCS n\u011bkolik hodin po vyno\u0159en\u00ed nad hladinu n\u00e1sleduj\u00edc\u00edmi p\u0159\u00edznaky: slabost\u00ed a necitlivost\u00ed v noh\u00e1ch a postupuj\u00edc\u00edmi senzorick\u00fdmi i motorick\u00fdmi poruchami. Tyto jevy nazna\u010duj\u00ed posti\u017een\u00ed m\u00edchy – hlavn\u011b zadn\u00edch a postrann\u00edch sloupc\u016f. Histopatologick\u00e9 v\u00fdzkumy zam\u011b\u0159en\u00e9 na DSC v souvislosti s nedostatkem vitam\u00ednu B12 uk\u00e1zaly spongi\u00e1ln\u00ed (houbovit\u00e9) zm\u011bny a ohniska po\u0161kozen\u00ed myelinu i axon\u016f v b\u00edl\u00e9 m\u00ed\u0161n\u00ed hmot\u011b.<\/p>\n

Nejposti\u017een\u011bj\u0161\u00ed jsou zadn\u00ed sloupce v oblasti hrudn\u00ed a kr\u010dn\u00ed p\u00e1te\u0159e, ale ke zm\u011bn\u00e1m doch\u00e1z\u00ed i v postrann\u00edch sloupc\u00edch. K patologick\u00fdm n\u00e1lez\u016fm v perifern\u00ed nervov\u00e9 soustav\u011b pat\u0159\u00ed axon\u00e1ln\u00ed degenerace a v\u00fdznamn\u00e1 demyelinizace (ztr\u00e1ta myelinov\u00e9ho ochrann\u00e9ho obalu nerv\u016f). V p\u0159\u00edpad\u011b akutn\u00edho DCS zp\u016fsobuj\u00ed bublinky vaskul\u00e1rn\u00ed obstrukci v tepn\u00e1ch i \u017eil\u00e1ch a uvol\u0148ov\u00e1n\u00ed bublinek plynu v m\u00ed\u0161e s pr\u016fvodn\u00ed spongi\u00f3zou, axon\u00e1ln\u00edm otokem a degenerac\u00ed myelinu.<\/p>\n

U opic dr\u017een\u00fdch po dlouhou dobu na diet\u011b zp\u016fsobuj\u00edc\u00ed nedostatek vitam\u00ednu B12 se objevily neuropatologick\u00e9 zm\u011bny nerozeznateln\u00e9 od zm\u011bn vyskytuj\u00edc\u00edch se u lid\u00ed, a to za dobu srovnatelnou s \u010dasem pot\u0159ebn\u00fdm ke spot\u0159ebov\u00e1n\u00ed z\u00e1sob vitam\u00ednu B12 u pacient\u016f trp\u00edc\u00edch pernici\u00f3zn\u00ed (zhoubnou) an\u00e9mi\u00ed. U zde zmi\u0148ovan\u00e9ho pot\u00e1p\u011b\u010de byla v\u0161ak pernici\u00f3zn\u00ed an\u00e9mie vylou\u010dena Schillingov\u00fdm testem.<\/p>\n

Nejd\u016fle\u017eit\u011bj\u0161\u00edm c\u00edlem p\u0159i l\u00e9\u010db\u011b nedostatku vitam\u00ednu B12 je co nejd\u0159\u00edve doplnit jeho z\u00e1soby v t\u011ble a n\u00e1sledn\u011b co nejd\u00e9le zabr\u00e1nit jeho nedostatku. Na \u00favod terapie se doporu\u010duje podat celkem 12 d\u00e1vek 1 mg vitam\u00ednu B12 jednou t\u00fddn\u011b a pot\u00e9 pokra\u010dovat s d\u00e1vkami 1 mg B12 jednou za 3 m\u011bs\u00edce. V\u0161echny neurologick\u00e9 p\u0159\u00edznaky se v\u011bt\u0161inou v\u00fdrazn\u011b zlep\u0161\u00ed b\u011bhem 3 – 6 m\u011bs\u00edc\u016f l\u00e9\u010dby, potom se zlep\u0161uj\u00ed pomalu a postupn\u011b b\u011bhem jednoho roku i d\u00e9le.<\/p>\n

Dosp\u011bli jsme k z\u00e1v\u011bru, \u017ee v tomto p\u0159\u00edpad\u011b byl pot\u00e1p\u011b\u010d posti\u017een DSC s akutn\u00edmi p\u0159\u00edznaky n\u00e1sledkem dekompresn\u00edho ponoru. Byl ohro\u017een kv\u016fli m\u00ed\u0161e “zraniteln\u00e9” z d\u016fvodu dlouhodob\u00e9ho nedostatku vitam\u00ednu B12. Domn\u00edv\u00e1me se, \u017ee i n\u011bkter\u00e9 p\u0159\u00edznaky v postterapeutick\u00e9m obdob\u00ed byly projevem nedostatku B12 umocn\u011bn\u00e9ho dekompresn\u00edm onemocn\u011bn\u00edm DSC. Nicm\u00e9n\u011b si nemysl\u00edme, \u017ee by vegetari\u00e1ni byli n\u011bjak v\u0161eobecn\u011b ohro\u017eeni onemocn\u011bn\u00edm DSC, i kdy\u017e je nutn\u00e9, aby sledovali sv\u016fj nutri\u010dn\u00ed stav, hlavn\u011b pak dostatek vitam\u00ednu B12.<\/p>\n

Kontaktn\u00ed \u00fadaje na autory: <\/strong><\/p>\n

Robert A van Hulst<\/strong>, MD, PhD, Diving
Medical Center, Royal Netherlands Navy,
PO Box10.000, 1780 CA Den Helder,
The Netherlands –
Email: ra.v.hulst@mindef.nl<\/a><\/p>\n

Win van der Kamp<\/strong>, MD, PhD,
Department of Neurology,
Medical Center Leeuwarden,
PO Box 888, 8901 BR Leeuwarden,
The Netherlands<\/p>\n","protected":false},"excerpt":{"rendered":"

(Pozn\u00e1mka vydavatele: Uv\u00e1d\u00edme zkr\u00e1cenou verzi \u010dl\u00e1nku Dekompresn\u00ed onemocn\u011bn\u00ed u pot\u00e1p\u011b\u010de vegetari\u00e1na. Hroz\u00ed vegetari\u00e1nsk\u00fdm pot\u00e1p\u011b\u010d\u016fm v\u011bt\u0161\u00ed riziko? Tato p\u0159\u00edpadov\u00e1 studie byla zve\u0159ejn\u011bna v “Caisson”, 26. ro\u010dn\u00edk…<\/p>\n","protected":false},"author":1,"featured_media":11373660,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[384],"tags":[],"authors":[1648],"class_list":["post-11385520","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-clanky","authors-robert-a-van-hulst-cs_cz"],"acf":[],"yoast_head":"\nDekompresn\u00ed onemocn\u011bn\u00ed u pot\u00e1p\u011b\u010de vegetari\u00e1na - Alert Diver<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/alertdiver.eu\/cs_CZ\/clanky\/dekompresni-onemocneni-u-potapece-vegetariana\/\" \/>\n<meta property=\"og:locale\" content=\"cs_CZ\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Dekompresn\u00ed onemocn\u011bn\u00ed u pot\u00e1p\u011b\u010de vegetari\u00e1na - Alert Diver\" \/>\n<meta property=\"og:description\" content=\"(Pozn\u00e1mka vydavatele: Uv\u00e1d\u00edme zkr\u00e1cenou verzi \u010dl\u00e1nku Dekompresn\u00ed onemocn\u011bn\u00ed u pot\u00e1p\u011b\u010de vegetari\u00e1na. 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