Comparing Sequential Organ Failure Assessment Score, Acute Physiology and Chronic Health Evaluation II, Modified Acute Physiology and Chronic Health Evaluation II, Simplified Acute Physiology Score II and Poisoning Severity Score for Outcome Prediction of Pesticide Poisoned Patients Admitted to the Intensive Care Unit

Objective

This study aimed to assess the severity of poisoning, various scoring systems, including Sequential Organ Failure Assessment (SOFA) score, acute physiology and chronic health evaluation II (APACHE II), Simplified Acute Physiology Score (SAPS II), Modified APACHE II, and poisoning severity score (PSS) were used. In this study, we compared the predictive value of these scoring systems on the outcome of pesticide-poisoned patients.

Methods

This is a cross-sectional study of pesticide-poisoned patients (140 patients) who were admitted to the intensive care unit (ICU) of Khorshid Hospital, Isfahan, Iran, between January 2015 and 2019. The area under the receiver operating characteristic (AUC) curve and the predictive value of scoring systems were compared.

Findings

Poisoning was higher in the male population (72.8%). The causes of poisoning were paraquat, (38.6%), aluminum phosphide, (32.1%), and organophosphate, (29.3%). The mean age of the patients was 33.9 years. Most patients (79.3%) attempted suicide. The mortality rate was 46.43%. The mean of "SOFA score," "APACHE II," "SAPS II," "Modified APACHE II," and "PSS" was 5.9; 15.7; 30.02; 15.8; and 1.9, respectively. There was a significant difference in the mean of all scoring systems for outcome prediction. Among all scoring systems, the SAPS II score with the cutoff point (16.5) had the best criteria for outcome prediction (AUC (0.831 ± 0.037), sensitivity (83.1%, 95% confidence interval [CI]: [71.7-91.2]), specificity (75.7%, 95% CI: [64.3-84.9]), positive predictive values (75.0%, 95% CI: [66.4-82.0]), negative predictive values (83.6%, 95% CI: [74.5-89.9]).

Conclusion

The SAPS II scoring system may be a suitable indicator for outcome predictions in pesticide-poisoned patients in the ICU.

Assessment of glufosinate-containing herbicide exposure: A multi-center retrospective study

BACKGROUND

Exposure to glufosinate ammonium, an herbicide used worldwide, can cause CNS and respiratory toxicities. This study aimed to analyze acute human glufosinate ammonium poisoning.

MATERIALS AND METHODS

This multicenter retrospective cohort study involved five medical institutes affiliated with the Chang Gung Memorial Hospital system. Patients with glufosinate ammonium exposure visiting the emergency department (ED) between January 2008 and December 2020 were included.

RESULTS

In total, 95 patients were enrolled. Compared to exposure via the non-oral route, patients exposed orally (n = 61) had lower GCS scores, higher mortality rates, and longer hospital lengths of stay (P-value: <0.001, 0.002, and < 0.001, respectively). In the subgroup analysis among oral exposure patients, the survival group had a lower amount of estimated glufosinate ingestion than the non-survival group (10.5 [3.4-27] vs. 40.5 [27-47.3] g, P-value: 0.022), lower rate of substance co-exposure (9 [19.6%] vs. 10 [66.7%] P-value: 0.001), and lower rate of paraquat co-exposure (0 [0%] vs. 7 [46.7%] P < 0.001) compared with the mortality group. In the orally-exposed and non-paraquat co-exposure patients (n = 54), age > 70 years and GCS score < 9 at triage presented a high sensitivity (100.00%, 95% CI: 63.06-100.00%) and medium specificity (58.70%, 95% CI: 43.23-73.00%) in predicting mortality.

CONCLUSION

Old age, change in consciousness, and paraquat co-exposure were associated with higher mortality in human glufosinate poisoning. Age > 70 years and GCS score < 9 at triage could be predictors of mortality in patients with acute oral glufosinate poisoning.

Relationship between acute kidney injury and mortality in poisoning - a systematic review and metanalysis

RATIONALE

Three consensus classifications of acute kidney injury have been published. These are RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease published by the Acute Dialysis Quality Initiative workgroup), AKIN (published by the Acute Kidney Injury Network) and KDIGO (published by the Kidney Disease Improving Global Outcome workgroup). Acute kidney injury has been reported consistently as associated with worsened outcomes. However, toxicant-related acute kidney injury has been excluded from the studies used to validate the classifications of acute kidney injury.

OBJECTIVE

To study whether poisoned patients who develop acute kidney injury, as defined by consensus definitions/classifications, have higher mortality compared to those who did not.

METHODS

Databases were searched from 2004 to 2019 using the following keywords (KDIGO OR "Kidney Disease: Improving Global Outcomes" OR "Kidney Disease Improving Global Outcomes" OR AKIN OR "AKI network" OR "Acute kidney Injury Network" OR ADQI OR RIFLE OR "Acute dialysis quality initiative") AND (intoxication OR poisoning OR overdose OR ingestion) AND (AKI OR kidney OR renal OR ARF). If data were available, we used a random-effects meta-analysis model and Fisher's exact test to compare mortality in patients according to kidney function definitions (acute kidney injury vs not) and stages (stages vs no acute kidney injury), respectively. If data were available, we assessed the correlation between mortality and renal function (no acute kidney injury, risk/stage 1, injury/stage 2 and failure/stage 3) using the Spearman correlation. If available, we collected the results of statistical analyses in studies that have used acute kidney injury to predict mortality.

RESULTS

Study selection. Thirty-three relevant studies were found, 22/33 retrospective studies (67%) and 11/33 prospective studies (33%). Paraquat was the most frequent toxicant involved (13/33, 39%). We found a disparity between studies regarding the timeframe during which mortality was assessed, the temporality of the renal function considered to predict mortality (initial/worst) and the criteria used to define/grade acute kidney injury across studies. Univariate association between acute kidney injury definitions/stages and mortality. Consensus definitions/staging of acute kidney injury were associated with higher mortality, using univariate analyses, in twenty-eight (RIFLE = 7; AKIN = 12; KDIGO = 9) studies included but not in five (AKIN = 4, KDIGO = 1). When available data were pooled, RIFLE (5 studies), AKIN (16 studies) and KDIGO definitions (8 studies) of acute kidney injury were associated with a higher mortality (Log unadjusted Odds ratios [95%-confidence interval], 2.60 [2.23; 2.97], 2.02 [1.48; 2,52] and 3.22 [2,65; 3.78], respectively). However, we found high heterogeneity (I²=54,7%) and publication bias among studies using AKIN. In ten studies with available data, the correlation between renal function (no acute kidney injury, risk/stage 1, injury/stage 2, failure/stage 3) and mortality was significant in 5 studies (RIFLE = 2; AKIN = 3), but not in five studies (RIFLE = 1; AKIN = 3; KDIGO = 1).Multivariate association between acute kidney injury definitions/stages and mortality. The definitions of acute kidney injury were associated with higher mortality in two studies (RIFLE = 2), but not in four studies (AKIN = 1 and KDIGO = 3. The stages of acute kidney injury (including one or more stages) were associated with higher mortality in four (RIFLE = 1, AKIN = 1 and KDIGO = 2).

CONCLUSIONS

All three consensus definitions/classifications were associated independently with increased mortality in poisoning but with disparity between studies reporting acute kidney injury.

Increasing serum ammonia level is a risk factor for the prognosis of critically ill patients: A multicenter retrospective cohort study

PURPOSE

To assess the association between serum ammonia level upon admission during the initial intensive care unit (ICU) stay and mortality.

MATERIALS AND METHODS

This retrospective cohort study included 2703 adult patients in eICU Collaborative Research Database. The ICU mortality within ammonia deciles were assessed. Logistic regression analyses were performed to analyze the relationship between ammonia and mortality.

RESULTS

We defined three ammonia categories: <47, 47-111, and ≥111 μg/dL, corresponding to low, intermediate, and high ICU mortality. Increased ammonia was significantly associated with increased ICU mortality (per 10 μg/dL increase: odds ratio, 1.070 [95% confidence intervals, 1.05-1.09]; intermediate vs. low: 1.90 [1.41-2.56]; high vs. low: 4.38 [2.99-6.41]) and in-hospital mortality (1.06 [1.04-1.08]; 1.45 [1.13-1.87]; 3.41 [2.43-4.79]). Adding ammonia to the Acute Physiology and Chronic Health Evaluation (APACHE) IV score improved the area under the curve from 0.826 to 0.839 (P < 0.001) and from 0.806 to 0.813 (P = 0.001) for ICU and in-hospital mortality, respectively. Interaction and subgroup analyses demonstrated consistent results in patients with different APACHE IV scores, with or without hepatic diseases.

CONCLUSIONS

Elevated serum ammonia level in critically ill patients upon admission was an early risk factor for higher ICU and in-hospital mortality.