Diagnosis of acute intoxications in critically ill patients: focus on biomarkers - part 1: epidemiology, methodology and general overview

Predictive models assessing the impact of intensive care unit admission on the outcomes of acutely poisoned patients

Although intensive care unit (ICU) admission is the cornerstone in management of critically acute poisoned patients, the decision of ICU admission is often challenging, especially with limited resources. Hence, our study aimed to assess predictive models of the impact of ICU admission on outcomes of patients with acute poisoning. This retrospective cohort study recruited records of acutely poisoned patients admitted to Tanta University Poison Control Center between 2021 and 2023. Patient demographic and toxicological data, as well as initial clinical and laboratory profiles, were retrieved. Afterward, patients were categorized according to mortality and complicated outcomes. Out of 221 acutely poisoned patients admitted to the ICU, the incidences of mortality and complications in survivors were 54.3% and 57.4%, respectively. Aluminum phosphide (ALP) was the most common cause of poisoning (59%), with a significant association with mortality and predominance in cardiac complications. However, respiratory and neurological complications were evident among illicit substances, cholinesterase inhibitors, and neuropsychiatric drugs. The model anticipating morality included time from presentation to ICU admission, mean arterial pressure (MAP), oxygen saturation, pH, and ALP poisoning. Furthermore, the complication predictive model comprised time from exposure to poison center presentation, time from presentation to ICU admission, and MAP. Both models exhibited good to excellent discrimination performance and consistent calibration. Accordingly, prompt admission of all ALP-poisoned patients to ICU with a highly standardized level of care may alleviate their deleterious outcomes. However, drug categories with reversible courses should be adequately treated with frequent respiratory and hemodynamic monitoring in less-equipped ICUs.

Critical care management of acute intoxications, dynamics and changes over time: a cohort study

Acute intoxications and poisonings are a relevant cause for ICU admission of critically ill patients. This study aimed to determine the characteristics of intoxicated patients in a tertiary center medical ICU in Austria over time and to investigate parameters associated with ICU mortality. This study was a retrospective data analysis including adult ICU patients from the years 2007 to 2021. In addition to ICU documentation, pre-hospital, and emergency department documents as well as autopsy reports were utilized. In an exploratory subanalysis, we compared these findings to a historical dataset from our facility from 1992 to 1996. We identified 581 cases admitted to the medical ICU because of acute poisoning (2007-2021), of which 45% were female and 46.6% were mixed intoxications. Suicidal intent was the primary cause of intoxication (48.2%) and ICU length of stay was median 1.2 days. The majority of deceased patients received pre-hospital mechanical CPR. Primary and secondary poison/toxin removal modalities were used in 29.9% and 11.7% of cases, whereas antidotes were administered in 54.4%. Comparing the data with a historical cohort (n = 168), we found a shift in primary detoxification away from gastric lavage and an increase in alternative secondary poison/toxin removal techniques. The ICU mortality was 4.1% and 4.2% in the present and historic cohort, respectively. Pre-existing psychiatric illnesses increased from 49% in the historic to 69% in the present cohort. Psychiatric illness predisposes patients to severe intoxications necessitating ICU care, thus increasing prevention measures seems warranted. Females did present with a different spectrum of intoxications compared to males. ICU mortality remained low over time and most deceased patients had a grim prognosis already on ICU arrival.

The INTOXICATE study: methodology and preliminary results of a prospective observational study

BACKGROUND

There is currently no practice-based, multicenter database of poisoned patients admitted to intensive care units (ICUs). The INTOXICATE study, endorsed by the ESICM and EAPCCT, aimed to determine the rate of eventful admissions among acutely intoxicated adult ICU patients.

METHODS

Ethical approval was obtained for this multicenter, prospective observational study, and data-sharing agreements were signed with each participating center. An electronic case report form was used to collect data on patient demographics, exposure, clinical characteristics, investigations, treatment, and in-hospital mortality data. The primary outcome, 'eventful admission', was a composite outcome defined as the rate of patients who received any of the following treatments in the first 24 h after the ICU admission: oxygen supplementation with a FiO2 > 40%, mechanical ventilation, vasopressors, renal replacement therapy (RRT), cardiopulmonary resuscitation, antidotes, active cooling, fluid resuscitation (> 1.5 L of intravenous fluid of any kind), sedation, or who died in the hospital.

RESULTS

Seventy-eight ICUs, mainly from Europe, but also from Australia and the Eastern Mediterranean, participated. A total of 2,273 patients were enrolled between November 2020 and June 2023. The median age of the patients was 41 years, 72% were exposed to intoxicating drugs. The observed rate of patients with an eventful ICU admission was 68% (n = 1546/2273 patients). The hospital mortality was 4.5% (n = 103/2273).

CONCLUSIONS

The vast majority of patients survive, and approximately one third of patients do not receive any ICU-specific interventions after admission in an intensive care unit for acute intoxication. High-quality detailed clinical data have been collected from a large cohort of acutely intoxicated ICU patients, providing information on the pattern of severe acute poisoning requiring intensive care admission and the outcomes of these patients.

TRIAL REGISTRATION

OSF registration ID: osf.io/7e5uy.

Evaluation of the new poisoning mortality score in comparison with PSS and SOFA scoring systems to predict mortality in poisoned patients admitted to the intensive care unit

Objective

Mortality prediction in acute poisoning patients aids in prompt and effective treatment. This study aimed to evaluate the effectiveness of the new Poisoning Mortality Score (PMS) in comparison with the Poison Severity Score (PSS) and Sequential Organ Failure Assessment (SOFA) scoring systems in poisoned patients admitted to the intensive care unit (ICU).

Material and Methods

The medical records of 523 poisoned patients admitted to the ICU of the Poison Control Centre from September 2021 to June 2022 were examined retrospectively. The PMS, PSS, and SOFA scores were calculated based on the worst values of the first 24 h of admission.

Results

A total of 100 patients were enrolled in the study, and the in-hospital mortality rate was 28%. The best cut-off points for predicting mortality for PMS, PSS, and SOFA scores were > 53, > 2, and > 6, with sensitivities of 67.9%, 85.7%, and 82.4% and specificities of 73.6%, 84.7%, and 83.3% respectively. In a pairwise comparison of the AUCs for PMS, PSS, and SOFA scores, SOFA displayed significantly greater accuracy than PSS and PMS.

Conclusion

The PMS, PSS, and SOFA scoring systems were significant predictors of mortality in ICU-admitted poisoned patients, however, the SOFA score showed the best performance (OR = 1.77, and 95% CI = 1.42-2.54) with significant P-value (0.002) as a predictor of mortality and highest AUC(0.904).

Prediction of troponin I and N-terminal pro-brain natriuretic peptide levels in acute carbon monoxide poisoning using advanced electrocardiogram analysis, Alexandria, Egypt

The study aimed at assessing the diagnostic ability of advanced electrocardiogram (ECG) analysis to predict the levels of NT-proBNP and Troponin I. ECG and the blood NT-proBNP and Troponin I were taken from 50 acutely carbon monoxide poisoned patients and 21 control subjects matched with age and sex. The severity of the studied cases was classified into mild, moderate, and severe using clinical classification. ECG parameters (RR interval, corrected QT (QTc) interval, P wave dispersion (Pwd)), and cardiac biomarkers (NT-proBNP and Troponin I) were significantly higher in cases than in control (p= 0.015, 0.008, 0.002, <0.001, and <0.001 respectively). Cut-off values resulted from combined ROC curves analysis can predict blood Troponin I more than 0.05 ng/ml and NT-proBNP more than 125 pg/ ml (with 88% and 84% accuracy respectively). In addition, two regression equations were developed using all studied ECG parameters to predict Troponin I and NT-proBNP (with 68% and 43% accuracy respectively). RR average, PR average, QRS average, QTd, QTc, and Pwd could be used to predict Troponin I and NT-proBNP levels with good accuracy in carbon monoxide poisoning patients.

Clinical and Epidemiological Characteristics of Severe Acute Adult Poisoning Cases in Martinique: Implicated Toxic Exposures and Their Outcomes

The epidemiology of severe acute poisonings in the French overseas departments of the Americas remains poorly reported. The main objective of this study was to determine the epidemiology and characteristics of severe acutely poisoned adult patients.

METHODS

A retrospective descriptive study was conducted from 1 January 2000 to 31 December 2010 in severely poisoned patients presenting to the emergency department (ED) of the University Hospital of Martinique, and the general public hospitals of Lamentin and Trinité.

RESULTS

During the study period, 291 patients were admitted for severe poisoning, giving an incidence rate of 7.7 severe cases/100,000 inhabitants. The mean age was 46 ± 19 years and 166 (57%) were male. Psychiatric disorders were recorded in 143 (49.8%) patients. Simplified Acute Psychological Score (SAPS II) at admission was 39 ± 23 points and Poisoning Severity Score (PSS) was 2.7 ± 0.8 points. Death was recorded in 30 (10.3%) patients and hospital length of stay was 6 ± 7 days. The mode of intoxication was intentional self-poisoning in 87% of cases and drug overdose was recorded in 13% of cases. The toxic agent involved was a therapeutic drug in 58% and a chemical product in 52% of cases. The predominant clinical manifestations were respiratory failure (59%), hemodynamic failure (27%), neurologic failure (45%), gastrointestinal manifestations (27%), and renal failure (11%). Polypnea, shock, ventricular fibrillation or tachycardia, and gastro-intestinal disorders were the main symptoms associated with death. The main biological abnormalities associated with death in our patients were metabolic acidosis, hypokalemia, hyperlactatemia, hypocalcemia, renal injury, rhabdomyolysis, increased aspartate aminotransferases, and thrombocytopenia. Extracorporal membrane oxygenation (ECMO) was used in three patients and specific antidotes were used in 21% of patients.

CONCLUSIONS

Acute poisonings remain a major public health problem in Martinique with different epidemiological characteristics to those in mainland France, with a high incidence of poisoning by rural and household toxins.