Most Common Intoxication in Nephrology Ward Organophosphate Poisoning

The relationship of serum amylase levels in acute organophosphorus poisoning with its clinical severity and outcome: a cross-sectional study

There are limited literatures studying the pancreatic involvement in organophosphate (OP) poisoning using biochemical means. This study focused on assessing the type of OP poisoning and determining the association of serum amylase levels with the patient's presentation and outcome.

Materials and methods

A cross-sectional study was carried out in the Maharajgunj Medical Campus, Tribhuwan University Teaching Hospital, Kathmandu, Nepal, after ethical approval [Ref: IRB/308 (6-11-E)]. We collected data from 172 participants with OP poisoning over the period of 2 years using nonprobability purposive sampling method. All patients with age group 16-75 years having a history of OP poisoning within the previous 24 h with clinical features and physical evidence of poisoning were included in the study. Those participants with indications of exposure to an entirely different poisons, poisoning with multiple poisons, OP poisoning along with alcohol, chronic alcoholics, comorbid conditions, taking drugs that could affect serum amylase levels (azathioprine, thiazides, furosemide, etc.), and/or treated in other hospitals after poisoning were excluded from the study. Appropriate statistical calculations were made using the statistical package for social sciences (SPSS), version 21. The P-value of less than 0.05 was considered statistically significant.

Results

Metacid (53.5%, 92) was the most common OP poison. There were significantly higher mean values of serum amylase levels either within 12 h of exposure (468.60 vs. 135.4 IU/ml, P<0.001) or after 12 h of exposure (152.0 vs. 58.9 IU/ml, P<0.001) in dead participants than alive ones. The participants with initial and after 12 h of exposure-serum amylase level 100 or more IU/ml had more than two-fold and 18-fold higher odds of severe/life-threatening severity (odds ratio=2.40, 95% CI: 1.28-4.52, P=0.007 and odds ratio=18.67, 95% CI: 8.02-43.47, P<0.001) respectively than those with less than 100 IU/ml.

Conclusions

The clinical severity of OP poisoning is directly related to serum amylase levels. Importantly, higher mean values of serum amylase levels were depicted in those participants with OP poisoning culminating to death. Thus, serum amylase level could be one of the easy measurable prognostic marker of OP poisonings.

Impact of Serum Amylase Level in the Outcome of Acute Organophosphorus Poisoning: 2-Year Cross-Sectional Study at Rural Teaching Hospital

Introduction  Prompt recognition and aggressive management of acute intoxication due to organophosphorus poisoning are essential to minimize the morbidity and mortality. The present study was undertaken to know the prognosis and outcome of organophosphorus poisoning patients with the estimation of low-cost enzymes like the serum amylase level in a population with financial constraints.

Methods  In this cross-sectional study, we had enrolled 100 cases that had a history of exposure to organophosphorus compounds, and the serum amylase level was measured in all the patients. We assessed the outcome of all the patients in the form of discharge, need of ventilators, intensive care unit stay, and death.

Results  The mean serum amylase level in discharge patients was 335.40 ± 192.45, and in the patients who died it was 843.37 ± 22.60. It was significant to predict the outcome ( t -value 7.07, p -value 0.0001, statistically significant).

Conclusion  Serum amylase level shows significant correlation with clinical outcomes in organophosphorus poisoning.

Correlation and prognostic significance of serum amylase, serum lipase, and plasma cholinesterase in acute organophosphorus poisoning

Background:

Organophosphorus (OP) are substances that are originally produced by the reaction of alcohols and phosphoric acid. These OP compounds are the main components of herbicides, pesticides, and insecticides. These are easily available in developing country like India; there is lack of awareness about these chemicals which results in high morbidity and mortality.

Aims and Objectives:

To estimate levels of amylase, lipase, plasma cholinesterase in acute OP poisoning. To assess severity of OP poisoning by using plasma cholinesterase levels and correlating it with other two markers. Predicting the severity of acute OP poisoning by using these biochemical markers.

Materials and Methods:

A hospital-based observational study was conducted on 100 subjects who were clinically diagnosed of acute OP poisoning. Subjects of either gender of all age-groups were included in the study. On admission, plasma cholinesterase, serum amylase, and serum lipase were measured. Based on plasma cholinesterase activity at the time of admission, subjects were divided into three groups. Group I-having 20-50% of plasma cholinesterase activity; Group II-10-20% of plasma cholinesterase activity; and Group III <10% of plasma cholinesterase activity.

Results:

Among 100 patients it was seen that serum amylase and serum lipase were negatively correlated with plasma cholinesterase levels and it was statistically significant. It was seen that serum amylase had the highest diagnostic accuracy for assessing severity of poisoning, 10 deaths were there in which 6 had <10% of plasma cholinesterase activity, 8 out of these 10 patients had elevated amylase level.

Conclusion:

OP poisoning is associated with elevated amylase level. Serum amylase, lipase can be used as an additional prognostic indicator along with plasma cholinesterase levels. Serum amylase could be considered as a better predictor of severity than lipase.

Diagnosis of acute intoxications in critically ill patients: focus on biomarkers - part 2: markers for specific intoxications

In medical intensive care units, acute intoxications contribute to a large proportion of all patients. Epidemiology and a basic overview on this topic were presented in part one. The purpose of this second part regarding toxicological biomarkers in the ICU setting focuses on specific poisons and toxins. Following the introduction of anion and osmol gap in part one, it's relevance in toxic alcohols and other biomarkers for these poisonings are presented within this publication. Furthermore, the role of markers in the blood, urine and cerebrospinal fluid for several intoxications is evaluated. Specific details are presented, amongst others, for cardiovascular drug poisoning, paracetamol (acetaminophen), ethanol, pesticides, ricin and yew tree intoxications. Detailed biomarkers and therapeutic decision tools are shown for carbon monoxide (CO) and cyanide (CN^-) poisoning. Also, biomarkers in environmental toxicological situations such as mushroom poisoning and scorpion stings are presented.

Can we predict intermediate syndrome? A review

INTRODUCTION

Ingestion of organophosphorus insecticides (OPI) is a common method of deliberate self harm in the developing world. Deaths mainly follow as a result of the respiratory failure associated with both cholinergic crisis and the intermediate syndrome. Even though death can be prevented by early mechanical ventilation of these patients, limited studies are available regarding the prediction of intermediate syndrome and subsequent respiratory failure.

OBJECTIVE

To systematically review articles that are published with regard to possible prediction of intermediate syndrome using clinical, biochemical and electrophysiological parameters.

METHODS

A systematic review on literature published in English language was done in the PubMed database without a date limitation. Two sets of search terms were used. The first set consisted of MeSH Terms "organophosphates", "organophosphate poisoning", "op poisoning" "organophosphate insecticide poisoning" and "organophosphorus". The second set included the MeSH Terms "Intermediate syndrome", "proximal muscle weakness", "cranial nerve palsies", "respiratory depression" and "neck muscle weakness". Articles containing at least one word from each set were reviewed.

RESULTS

At least one MeSH term from each set was incorporated in 179 articles. Of these, 69 were rejected as they were not related to organophosphate poisoning or intermediate syndrome.

PREDICTION OF IMS

Clinical prediction is mostly based on ICU scoring systems. Biochemical markers such as reduced levels of serum and erythrocyte acetylcholine esterase have been studied many times. Both clinical and biochemical markers show a modest relationship in predicting IMS. Single fibre electromyography show promising results as it directly assesses neuromuscular junction.

CONCLUSION

The intermediate syndrome which follows organophosphate poisoning still remains a significant problem with its high morbidity. Clinical and biochemical markers show modest results in predicting IMS. Neurophysiological markers such as single fibre EMG should be studied further as they measure activity of affected nicotinic receptors directly.

The effectiveness of patient-tailored treatment for acute organophosphate poisoning

BACKGROUND

To determine a new pralidoxime (PAM) treatment guideline based on the severity of acute organophosphate intoxication patients, APACHE II score, and dynamic changes in serum butyrylcholinesterase (BuChE) activity.

METHODS

This is a randomization trial. All patients received supportive care measurements and atropinization. Each enrolled patient was treated with 2 gm PAM intravenously as the loading dose. The control group was treated according to the WHO's recommended PAM regimen, and the experimental group was treated according to their APACHE II scores and dynamic changes in BuChE activity. If a patient's APACHE II score was ≧26 or there was no elevation in BuChE activity at the 12th hour when compared to the 6th, doses of 1 g/h PAM (i.e., doubled WHO's recommended PAM regimen) were given. The levels of the serum BuChE and red blood cells acetylcholinesterase and the serum PAM levels were also measured.

RESULTS

Forty-six organophosphate poisoning patients were enrolled in this study. There were 24 patients in the control group and 22 patients in the experimental group. The hazard ratio of death in the control group to that of the experimental group was 111.51 (95% CI: 1.17-1.613.45; p = 0.04). The RBC acetylcholinesterase level was elevated in the experimental group but was not in the control group. The experimental group did not exhibit a higher PAM blood level than did the control group.

CONCLUSION

The use of PAM can be guided by patient severity. Thus, may help to improve the outcomes of organophosphate poisoning patients.

Prognostic significance of various biochemical parameters in acute organophosphorus poisoning

Background:

Organophosphorus (OP) compounds are a heterogeneous group of insecticides widely used in agricultural industry. These OP compounds are likely to have more adverse effects in developing countries like India due to its easy availability and less awareness which results in high morbidity and mortality.

Aims and objectives:

1. To estimate plasma cholinesterase, amylase, lipase and, creatine phosphokinase (CPK) in acute OP poisoning. 2. To correlate these biochemical parameters with plasma cholinesterase levels in OP poisoning. 3. To determine the use of a biochemical marker in predicting the severity of acute OP poisoning.

Materials and Methods:

A hospital based observational study was conducted on 53 subjects who have clinically diagnosed of acute OP poisoning and admitted in emergency unit of a tertiary care rural hospital. Subjects of either gender of all age-groups were included in the study. On admission, plasma cholinesterase, serum amylase, lipase and CPK were measured. Based on plasma cholinesterase activity at the time of admission, subjects were divided into three groups. Group I-having 20-50% of plasma cholinesterase activity; Group II-10-20% of plasma cholinesterase activity; and group III-<10% of plasma cholinesterase activity.

Results:

Serum amylase, lipase and CPK were negatively correlated with plasma cholinesterase levels. Serum amylase showed statistically significant negative correlation with plasma cholinesterase. Serum amylase showed the highest diagnostic accuracy for assessing severity of poisoning followed by CPK and Lipase.

Conclusion:

OP poisoning is associated with hyperamylasemia. Serum amylase, lipase and CPK can be used as an additional prognostic indicator with plasma cholinesterase levels. Serum amylase could be considered as a better predictor of severity followed by CPK and lipase.

Cases of organophosphate poisoning treated with high-dose of atropine in an intensive care unit and the novel treatment approaches

Organophosphate poisoning is a life-threatening condition, which is being responsible for the symptoms due to cholinergic effects. Clinical status and blood levels of cholinesterase are used its diagnosis. While atropine and pralidoxime (PAM) appear as essential medications, hemofiltration treatments and lipid solutions have been widely studied in recent years. In this study, the importance of high-dose atropine therapy and early intervention and novel treatment approaches are discussed. Records of a total of 25 patients treated for organophosphate poisoning in the intensive care unit (ICU) between April 2007 and December 2011 were evaluated retrospectively. Of the 25 patients, 14 (56%) were male and 11 (44%) were female with a mean age of 34.8 ± 17.66 years (range: 14-77 years). The patients were most frequently admitted in June (n = 4) and July (n = 4) (16%). Of the 25 patients, 22 patients (88%) were poisoned by oral intake, two (8%) by inhalation, and one (4%) by dermal route. Of them, 20 patients (80%) took organophosphates intentionally for suicidal purposes, while five (20%) cases poisoned due to accidental exposure. The scores of Glasgow Coma Scale of nine patients (36%) were below 8 point upon admission to hospital. The highest dose of atropine given was 100 mg intravenously on admission and 100 mg/h/day during follow-up. The total dose given was 11.6 g/12 days. A total of 11 patients (44%) were on mechanical ventilation for a mean duration of 5.73 ± 4.83 days. The mean duration of ICU stay was 6.52 ± 4.80 days. Of all, 23 patients (92%) were discharged in good clinical condition and one patient (4%) was referred to another hospital. This study suggests that atropine can be administered until secretions disappear and intensive care should be exerted in follow-up of these patients. In addition, in case of necessity for high doses, sufficient amounts of atropine and PAM should be available in hospitals.

A Fatal Case of Paraquat Poisoning Following Minimal Dermal Exposure

Paraquat is a pesticide widely used in agriculture. Numerous cases of paraquat intoxication have been reported either accidentally or intentionally as a suicidal attempt. The most severe cases of paraquat poisoning refer to oral ingestion. Complications include respiratory, hepatic, and renal failure, and are usually fatal. Dermal exposure is less frequent and rarely fatal. This article reports a case of an 81-year-old man with minimal skin burn after accidental paraquat exposure. The patient developed acute renal and respiratory failure and, despite aggressive treatment with hemodialysis, hemoperfusion, and mechanical ventilation, died two days later.

Epidemiology of organophosphate pesticide poisoning in Taiwan

INTRODUCTION

The nationwide epidemiology of organophosphate pesticide (OP) poisoning has never been reported in detail for Taiwan.

METHODS

This study retrospectively reviewed all human OP exposures reported to Taiwan's Poison Control Centers (PCCs) from July 1985 through December 2006.

RESULTS

There were 4799 OP exposures. Most OP exposures were acute (98.37%) ingestions (74.50%) of a single OP (80.37%) to attempt suicide (64.72%) in adults (93.25%). Males were the most common gender (64.95%). Most patients (61.97%) received atropine and/or pralidoxime. The mortality rate for all 4799 OP exposures was 12.71%. Exposures to single OPs without co-intoxicants caused 524 deaths; of these, 63.36% were due to dimethyl OPs.

CONCLUSION

Dimethyl OPs cause the majority of deaths in Taiwan.

Predicting outcome using butyrylcholinesterase activity in organophosphorus pesticide self-poisoning

BACKGROUND

The usefulness of a low butyrylcholinesterase (BuChE) activity on admission for predicting severity in acute organophosphorus (OP) insecticide poisoning has long been debated. Previous studies have been confounded by the inclusion of multiple insecticides with differing inhibitory kinetics.

AIM

We aimed to assess the usefulness of admission BuChE activity, together with plasma OP concentration, for predicting death with two specific organophosphorus insecticides.

DESIGN

A prospective cohort of self-poisoned patients.

METHODS

We prospectively studied 91 and 208 patients with proven dimethoate or chlorpyrifos self-poisoning treated using a standard protocol. Plasma butyrylcholinesterase activity and OP concentration were measured on admission and clinical outcomes recorded.

RESULTS

The usefulness of a plasma BuChE activity <600 mU/ml on admission varied markedly--while highly sensitive in chlorpyrifos poisoning (sensitivity 11/11 deaths; 100%, 95% CI 71.5-100), its specificity was only 17.7% (12.6-23.7). In contrast, while poorly sensitive for deaths in dimethoate poisoning [12/25 patients; 48%, (27.9-68.7)] it was reasonably specific [86.4% (75.7-93.6)]. A high OP concentration on admission was associated with worse outcome; however, a clear threshold concentration was only present for dimethoate poisoning.

CONCLUSION

Plasma BuChE activity on admission can provide useful information; however, it must be interpreted carefully. It can only be used to predict death when the insecticide ingested is known and its sensitivity and specificity for that insecticide has been studied. Plasma concentration of some OP insecticides predicts outcome. The development of rapid bedside tests for OP detection may aid early assessment of severity.

Organophosphate and carbamate intoxication in La Paz, Bolivia

Intoxication with organophosphate (OP) and carbamate (CM) compounds is a common reason for presentation to the Emergency Department (ED) in La Paz, Bolivia. The objective of this study was to describe the demographics, presenting symptoms, and hospital course of patients presenting with OP or CM intoxication to the ED of the Hospital de Clinicas, La Paz, Bolivia, with the aim of determining which factors might predict a complicated hospital course. This was a retrospective chart review, using predefined criteria, of 300 patients who presented from January 1, 2003 to December 31, 2003. The intoxications were all oral, mostly intentional (97%), and in young patients (mean age 23.9 years, range 13-62 years). Females outnumbered males almost 2:1. The most common symptoms on presentation were abdominal pain (83%), nausea/vomiting (79%), miosis (72%), bronchorrhea (44%), diarrhea (41%), and fasciculations (31%). The most frequent complications were aspiration (18%), cardiopulmonary arrest (9%), and seizure (7%); mortality was 6%. Treatments included gastric lavage in 96% of patients, and atropine (median 5 mg per patient, range 0-48 mg). Miosis, bronchorrhea, diarrhea, and fasciculations at presentation were associated with a higher rate of complications. Although almost all intoxications were suicide attempts, less than half of patients received a psychiatric consultation. OP intoxication is a common cause of self-inflicted morbidity and mortality among young people in La Paz, Bolivia. Presence of miosis, bronchorrhea, diarrhea, and fasciculations at presentation suggest a higher likelihood of complications.