The use of therapeutic plasmapheresis in the treatment of poisoned and snake bite victims: An academic emergency department's experiences

Redefining the role of therapeutic plasma exchange in complications of Echis carinatus sochureki envenomation refractory to anti-snake venom: A case series

INTRODUCTION

Saw-scaled viper (Echis carinatus) belongs to the Viperidae family. Its venom is hemotoxic and contains several small peptides and proteins affecting the coagulation system. Commonly used anti-snake venom (ASV) products in India are reported to be ineffective or less effective in cases with bites by Echis carinatus sochureki which are commonly found in desert areas in Rajasthan. Although therapeutic plasma exchange (TPE) has been successful in patients with snakebite envenomation in the past, American Society for Apheresis guidelines 2019 included this indication under category III with grade 2C recommendation.

AIM AND OBJECTIVES

To report the safety and efficacy of therapeutic plasma exchange procedures in the setting of ASV refractory E. c. sochureki envenomation.

MATERIALS AND METHODS

Four patients admitted to our institute in 2021 September with an alleged history of snake bites and who underwent at least one cycle of therapeutic plasma exchange were assessed for clinical outcome, laboratory parameters, and blood product consumption.

RESULTS

Three adult patients and one pediatric patient are included in this case series, all of them males. Indication for TPE in one case was suspected diffuse alveolar hemorrhage (DAH), while in all the other cases was thrombotic microangiopathy (TMA). All received a variable number of sessions from 2 to 5 and 1.3-1.5 plasma volume was removed on an average per cycle. The endpoint of TPE was the resolution of DAH in one while a reduction in lactate dehydrogenase and an increase in platelet count was in TMA cases. Consumption of blood products was drastically reduced in all four patients after starting the procedure. All the adult patients fared well on follow-up while the child had developed acute cortical necrosis and was dialysis-dependent. It has been noted in the previous studies too that a subset of snakebite-induced TMA cases was getting converted to chronic kidney disease and becoming dialysis dependent in the long run.

CONCLUSIONS

In regions where ASV treatment failure is very common, therapeutic plasma exchange is a safe and effective complementary treatment modality along with supportive care.

Therapeutic Plasma Exchange for Venom-Induced Thrombotic Microangiopathy Following Hump-Nosed Pit Viper (Genus: Hypnale) Bites: A Prospective Observational Study

INTRODUCTION

-Thrombotic microangiopathy (TMA), which is the triad of acute kidney injury (AKI), microangiopathic hemolytic anemia (MAHA), and thrombocytopenia, is a rare complication of snakebites, and in Sri Lanka, it is commonly seen with hump-nosed pit viper (HNPV) bites.

METHODS

-We conducted a prospective observational study of patients with AKI caused by HNPV bites in Teaching Hospital, Ratnapura, Sri Lanka for 6 y, commencing in June 2015. Some patients with TMA underwent therapeutic plasma exchange (TPE) and some did not. These 2 groups were compared. Statistical analysis was carried out using Minitab 18.1. Data were presented as median (IQR).

RESULTS

-There were 52 (8%) patients with TMA, of whom 21 (45%) were in the TPE group and 26 (55%) were in the non-TPE group. TPE improved time to platelet correction (4 d [IQR, 4-5 d] vs 7 d [IQR, 5-9 d]; P=0.009), time to MAHA correction (5 d [IQR, 3-4 d] vs 7 d [IQR, 6-9 d]; P=0.004), time to prothrombin time (PT)/international normalized ratio (INR) correction (1 d [IQR, 1-2 d] vs 3 d [IQR, 3-4 d]; P=0.003), and time to 20 min whole blood clotting test (WBCT20) correction (2 d [IQR, 1-2 d] vs 3 d [1QR 2-3 d]; P=0.020). Renal recovery was predicted by TPE (P=0.048) and highest creatinine level (P=0.001). There was no association between TPE and dialysis dependency at discharge (P=0.597), length of hospital stay (P=0.220), and the number of dialysis cycles prior to discharge (P=0.540). TPE did not improve the number of blood transfusions (5 packs [IQR, 3-8.5 packs] vs 4 packs [IQR, 0-9 packs]; P=0.290).

CONCLUSIONS

-TPE is effective for TMA in the early correction of platelet counts, MAHA, PT/INR, and WBCT20 in HNPV bites.

Thrombotic microangiopathy following saw-scaled viper (Echis carinatus) envenoming in Sri Lanka

The saw-scaled viper (Echis carinatus) is considered as a highly venomous snake in Sri Lanka. The clinical manifestations are localized pain and swelling, coagulopathy and renal impairment. Thrombotic microangiopathy is rarely reported as a complication of saw-scaled viper envenoming. The clinical manifestations of thrombotic microangiopathy include thrombocytopenia, microangiopathic haemolytic anaemia and acute kidney injury. The consumption coagulopathy of post-envenoming could be followed by a syndrome consistent with thrombotic microangiopathy. We describe a patient with thrombotic microangiopathy following saw-scaled viper systemic envenoming which was managed with antivenom and supportive therapy. The dead snake which was brought by patient was identified by medical professional as saw-scaled viper (E. carinatus) based on morphological features. This case illustrates a rare manifestation thrombotic microangiopathy following saw-scaled viper envenoming.

Snake Bite Management: A Scoping Review of the Literature

Background:

Around the world, snake bite envenomation remains an underreported human health hazard. Envenomation can cause local and systemic complications, especially when there is a lack of antivenom availability. Although there are established guidelines regarding snake bite management acute care, there is a paucity of data regarding surgical intervention and the plastic surgeon’s role treating this unique patient population.

Methods:

A review was conducted identifying relevant published articles involving snake bite management and treatment in PubMed and EMBASE.

Results:

One hundred ten articles were identified and 77 met inclusion criteria. Snake bite envenomation can result in complications that are dependent upon a variety of variables. The literature has shown the best field treatment to be timely transportation to the nearest medical facility, along with antivenom administration. The cytotoxic, hemotoxic, and neurotoxic effects of venom can cause a variety of local soft tissue and systemic complications. Surgical interventions such as fasciotomies, wound debridements, skin grafts, and tissue flaps may be necessary in these patients to optimize functional and aesthetic outcomes. Disparities in access to care in resource limited settings are discussed.

Conclusions:

Global health disparities and insufficient antivenom distribution create an inequality of care in snake bite patients. Plastic surgeons have an important role in managing acute and chronic complications of snake bite envenomations that can lead to improved patient outcomes.

Massive bee envenomation treated by therapeutic plasma exchange

In the unfortunate event of massive envenomation and precipitation of multiorgan failure, therapeutic plasma exchange (TPE) can be considered as a modality for therapy. We present a patient case where TPE potentially allowed for removal of toxin with subsequent clinical improvement.

Thrombotic Microangiopathy Following Arabian Saw-Scaled Viper (Echis coloratus) Bite: Case Report

BACKGROUND Consumption coagulopathy post envenomation is one the most common complications after a snakebite. It occurs secondary to activation of a coagulation cascade by snake venom and could be followed by a syndrome consistent with thrombotic microangiopathy. The efficacy of plasma exchange for the treatment of thrombotic microangiopathy post envenomation is a matter of debate. CASE REPORT We reported the case of a 50-year-old male who had Arabian saw-scaled viper envenomation. He developed venom induced coagulopathy that improved within 24 hours of antivenom therapy. He subsequently developed micro-angiopathic hemolytic anemia, thrombocytopenia, and renal failure that was consistent with thrombotic microangiopathy. The patient was treated by plasma exchange and hemodialysis. He made a full recovery and was discharged after 4 weeks. CONCLUSIONS This case report supports plasmapheresis as an option for management of a patient who develops thrombotic microangiopathy secondary to snake bite, especially those who do not improve with antivenom and supportive therapy.

Plasmapheresis in a case of acute kidney injury with severe hemolysis and thrombocytopenia due to hematotoxic (Russell's viper) snake bite

We present a case of a male patient after being bitten by a vasculotoxic snake (Russell's viper) with severe hemolysis, thrombocytopenia, and acute kidney injury requiring hemodialysis. As attempt to administer anti-snake venom (ASV) failed because of development of anaphylactic reaction, a single session of plasmapheresis was done to stop hemolysis and fall in platelets, which was refractory to all other measures and proved to be a lifesaving procedure in this patient. The role of plasmapheresis in the management of snakebite victims is yet to be established, but can be beneficial in snake bite victims refractory to ASV or nonavailability of ASV or intolerant to ASV as in this case.

Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue

The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.

Extracorporeal treatment in children with acute severe poisoning

Acute poisoning in children is a clinical emergency. Prompt and effective treatment is critical for life-threatening poisoning. Extracorporeal treatment (ECTR) is a practical option for enhancing the elimination of poisons.We conducted a retrospective observational study on 338 children with severe acute poisoning who received ECTR during hospitalization from January 2010 to December 2017. The poisonous substances, utilization of ECTR, adverse reactions to ECTR, and outcomes were recorded.The top 3 poisoning categories, in order of frequency, were found to be pesticides (57.99%), biotoxins (25.15%), and pharmaceuticals (14.20%). Paraquat (35.21%), an organic heterocyclic herbicide with high toxicity to humans, was the most common toxic substance. The main modalities of ECTR use were hemoperfusion (50.59%) and therapeutic plasma exchange (42.60%), followed by continuous renal replacement therapy (4.44%) and hemodialysis (1.18%). There were also 4 patients (1.18%) with a combination of ECTR performed. Adverse events of ECTR included errhysis and hematomas around the catheter exit site, oral cavity bleeding, allergic reactions, hypothermia, hypotension, and blood coagulation. The adverse reactions were mostly mild to moderate and were manageable. During the study period, there were 295 patients (87.28%) who were cured, 9 (2.66%) who experienced some improvement, and 34 (10.06%) who died.ECTR modalities were found to be clinically effective approaches to the treatment of poisoning by pesticides, biotoxins, and pharmaceuticals, indicating they are important modalities in toxicology and treatment, and are well tolerated by children.

Therapeutic plasma exchange for pediatric nonrenal disease indications and outcomes: A single-center experience

INTRODUCTION

Outcome data in pediatric plasma exchange, especially in nonrenal indications are scarce. We aimed to evaluate its role and outcome in our patients.

SUBJECTS AND METHODS

A retrospective study of children admitted in the year 2016 to the Pediatric Intensive Care Unit requiring plasma exchange for nonrenal indications was undertaken. Plasma exchange was given as adjunctive therapy along with primary treatment for the disease concerned. Demographic and clinical data were studied, and descriptive statistical analysis was carried out.

RESULTS

Ten children underwent plasma exchange during this 1-year period with a male: female ratio of 3:2 and a mean age of 10 years (range 3-16 years). The indications were acute disseminated encephalomyelitis (n = 2), acute neuromyelitis optica (n = 1), catastrophic antiphospholipid antibody syndrome secondary to systemic lupus erythematosus (SLE) (n = 1), severe SLE with cerebritis/hemophagocytic lymphohistiocytosis (HLH) (n = 2), severe dengue sepsis with HLH/multi-organ dysfunction syndrome (n = 2), and thrombotic microangiopathy secondary to snake bite envenomation (n = 2). All received either 1.5 or 2 times plasma volume exchange (mean sessions - 4, range = 1-6). The mean duration of stay in hospital was 17.2 days (range = 3-40 days), and follow-up was 78 days (range = 3-180 days), with the majority of children (8/10, 80%) survived from the catastrophic illness at the time of discharge. Two children (2/10, 20%) succumbed due to the disease per se in severe dengue sepsis in one and enterobacteriaceae sepsis (hospital-acquired pneumonia) in another.

CONCLUSION

Plasma exchange was found to be beneficial as complementary therapy in a critical care setting, especially for nonrenal indications.

Guidelines on the Use of Therapeutic Apheresis in Clinical Practice-Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Seventh Special Issue

The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating, and categorizing indications for the evidence-based use of therapeutic apheresis in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the Committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Seventh Edition of the JCA Special Issue continues to maintain this methodology and rigor to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Seventh Edition, like its predecessor, has consistently applied the category and grading system definitions in the fact sheets. The general layout and concept of a fact sheet that was used since the fourth edition has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. The Seventh Edition discusses 87 fact sheets (14 new fact sheets since the Sixth Edition) for therapeutic apheresis diseases and medical conditions, with 179 indications, which are separately graded and categorized within the listed fact sheets. Several diseases that are Category IV which have been described in detail in previous editions and do not have significant new evidence since the last publication are summarized in a separate table. The Seventh Edition of the JCA Special Issue serves as a key resource that guides the utilization of therapeutic apheresis in the treatment of human disease. J. Clin. Apheresis 31:149-162, 2016. © 2016 Wiley Periodicals, Inc.

Therapeutic Plasma Exchange for Refractory Hemolysis After Brown Recluse Spider (Loxosceles reclusa) Envenomation

INTRODUCTION

The brown recluse spider (BRS) (Loxosceles reclusa) envenomation can lead to multiple complications, including hemolysis. We present a case of refractory hemolysis after a BRS bite treated with therapeutic plasma exchange (TPE).

CASE REPORT

A 17-year-old female presented with fever, fatigue, and dyspnea. She was diagnosed with sepsis and received intravenous (IV) fluids, inotropic support, and antibiotics. On hospital day 1 she was noted to have skin lesion consistent with a BRS bite and developed hemolysis. Systemic loxoscelism with hemolysis was then suspected and methylprednisolone IV was initiated. She was discharged with a stable HGB on hospital day 3 on oral prednisolone. She was re-admitted 24 h later, with signs of worsening hemolysis. Methylprednisolone was restarted and she was transfused 4 units of packed red blood cells. TPE was initiated due to the refractory hemolysis. Shortly after the TPE session, her clinical and laboratory status improved. She required no further transfusions and was discharged on a steroid taper.

DISCUSSION

TPE is an extra-corporeal method to remove substances from the blood by separating plasma from cellular blood components and replacing it with physiologic fluids. TPE has been used for snake envenomation but there are no reports detailing its use for BRS envenomations. Improvement was associated with TPE initiation and may have been due to removal of complement components activated by the spider venom. This report suggests that TPE could be a possible treatment modality for systemic loxoscelism with refractory hemolysis due to BRS envenomation. Further investigation is warranted.

Recovery from AKI following multiple wasp stings: a case series

BACKGROUND AND OBJECTIVE

To observe the outcomes of AKI following multiple wasp stings.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Eighty-one patients (mean age ± SD, 45.5 ± 14.7 years; 55 men and 26 women; mean Acute Physiology and Chronic Health Evaluation II score, 16.85 ± 2.78) with AKI following multiple wasp stings between 1997 and 2011 were retrospectively analyzed. Data on their demographic characteristics, initial modalities of renal replacement therapy (RRT), urine output, serum creatinine, bilirubin, myoglobin, and other variables were collected. Renal outcomes included complete recovery of kidney function, CKD, and death. Subgroup analysis was performed according to initial modality of RRT in the first 48 hours, including continuous veno-venous hemofiltration (CVVH), intermittent hemodialysis (IHD), and CVVH plus plasma exchange (PE).

RESULTS

Of the 75 patients available for follow-up, 7 (9.3%) died, and 8 (10.7%, all in the IHD group) developed CKD. The average RRT time was 18.2 ± 8.4 days, and the average kidney function recovery time was 36.0 (29.0, 41.0) days. Subgroup analysis showed no difference in the mortality rates between the CVVH, CVVH + PE, and IHD groups (8.0%, 7.1%, and 11.1%, respectively; P>0.99). The recovery time for kidney function was significantly shorter in the CVVH and CVVH + PE groups than in the IHD group (31.9 ± 8.5 days, 28.6 ± 9.4 days, and 41.6 ± 8.1 days, respectively; P<0.001).

CONCLUSIONS

This is a large case series report on the outcomes of patients with AKI following multiple wasp stings. Most patients survived with complete recovery of their kidney function. Despite the lack of difference in mortality rates, the patients who began RRT with CVVH and CVVH + PE experienced a better and more rapid recovery of kidney function than those initiated with IHD.

Oxidant/antioxidant status in cases of snake bite

BACKGROUND

Snake bites are an important cause of mortality and morbidity worldwide, especially in rural areas.

OBJECTIVE

The aim of this study was to investigate serum paraoxonase (PON), arylesterase (ARLY), ceruloplasmin (Cp), and myeloperoxidase (MPO) activity and lipid hydroperoxide (LOOH) and total sulfhydryl group (-SH) levels in patients with snake venom poisoning.

METHODS

The study included 49 patients with snake bite envenomation (Group 1) and 39 healthy volunteers as the control group (Group 2). Plasma PON, ARLY, Cp, and MPO activity and LOOH and -SH levels were measured. Laboratory measurements of 20 patients with snake bite envenomation (Group 3) were performed again after treatment.

RESULTS

PON and ARLY activity and -SH levels were significantly decreased in Group 1 compared with those in Group 2. Cp and MPO activity and LOOH levels were significantly elevated in Group 1 compared with those in Group 2. PON and ARLY activity were significantly elevated in Group 3 compared with those in Group 1. Cp and MPO activity and LOOH levels were significantly decreased in Group 3 compared with those in Group 1.

CONCLUSIONS

Patients with snake bite envenomation had increased oxidants (MPO and LOOH) and decreased antioxidants (PON, ARLY, and -SH). Results obtained in this study demonstrate that snake bites are associated with a shift to oxidative status. Therapy with antioxidants can lead to an increase in the antioxidant defense system, and thus improvements in clinical symptoms.

Thrombotic microangiopathy and acute kidney injury in hump-nosed viper (Hypnale species) envenoming: a descriptive study in Sri Lanka

Hump-nosed viper (Hypnale species) bites are common in Sri Lanka and a proportion of these bites lead to coagulation abnormalities and acute kidney injury (AKI). We observed thrombotic microangiopathy (TMA) among some of these patients, but its contribution to severity of AKI and other morbidities remains unknown. Thus, we report a case series of TMA following hump-nosed viper bite addressing the complications and renal out comes in Sri Lanka. This was a prospective observational study carried out at the nephrology unit, Kandy in Sri Lanka from October 2010 to October 2011 and included 11 patients with AKI following hump-nosed viper bites. All eleven cases needed renal replacement therapy (RRT) with intermittent haemodialysis for a period of 1-5 weeks. Of them, 7 patients developed TMA with evidence of microangiopathic haemolytic anaemia (MAHA), thrombocytopenia and severe anaemia needing multiple blood transfusions. They needed longer duration of RRT (range 2-5 weeks); 2 patients developed chronic kidney disease and two died during acute stage. Autopsy study found thrombosis of micro-vessels. Thrombotic microangiopathy could be a causative pathology of AKI in hump-nosed viper bite carrying poor outcome.

The role of therapeutic plasma exchange in poisonings and intoxications

Poisonings, intoxications, and drug overdoses are common occurrences and rapid lowering of the toxin level is a cornerstone of all effective therapies. Therapeutic plasma exchange (TPE) has several unique characteristics that allow it to be a potentially effective therapy in rapidly achieving this goal. Specifically, TPE allows for the removal of large molecular weight, protein-bound molecules that have a small volume of distribution. Due to the nature of poisonings, intoxications, and drug overdoses, no randomized controlled trials studying the efficacy of TPE in these situations exist. Thus, careful interpretation and analysis of case reports and series are required to assess the potential efficacy of this therapy. Recent data suggest that TPE may also be effective in the therapy of patients receiving biologic treatments who develop life-threatening complications due to therapy.

Guidelines on the use of therapeutic apheresis in clinical practice--evidence-based approach from the Apheresis Applications Committee of the American Society for Apheresis

The American Society for Apheresis (ASFA) Apheresis Applications Committee is charged with a review and categorization of indications for therapeutic apheresis. Beginning with the 2007 ASFA Special Issue (fourth edition), the subcommittee has incorporated systematic review and evidence-based approach in the grading and categorization of indications. This Fifth ASFA Special Issue has further improved the process of using evidence-based medicine in the recommendations by refining the category definitions and by adding a grade of recommendation based on widely accepted GRADE system. The concept of a fact sheet was introduced in the Fourth edition and is only slightly modified in this current edition. The fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis. The article consists of 59 fact sheets devoted to each disease entity currently categorized by the ASFA as category I through III. Category IV indications are also listed.

Urgent liver transplantation for Amanita phalloides poisoning

Amanita phalloides is a deadly wild mushroom causing severe damage in man ranging from diarrhea to organ dysfunction. If not treated, mortality is as high as 80%. Treatment includes supportive measures, inactivation of the toxin and if liver failure occurs liver transplantation. The indications for transplantation are debatable.

Plasma exchange as treatment for Lawsone (henna) intoxication

Lawsone (2-hydroxy-1,4-naphthoquinone) is the active ingredient of Lawsonia alba, whose crushed leaves are known as henna, used as a hair and skin dye in many parts of the world. Accidental or deliberate ingestion of Lawsone has a high mortality rate (up to 31%) owing to rhabdomyolysis and renal failure. The authors report the first successful use of plasmapheresis as an adjunct to the treatment of these symptoms in a 69-year-old man who suffered severe symptoms of Lawsone poisoning due to inadvertent ingestion. Although most cases reported in the literature have been treated using supportive techniques, including hemodialysis, the high mortality despite these measures suggests that prompt plasma exchange may be a lifesaving technique for this syndrome.