Electroneurophysiological monitoring as an early severity predictor in acute anticholinesterase poisoned patient and the effect of oxime therapy manipulation

The neuromuscular transmission failure in acute anticholinesterases [e.g. organophosphorus compounds and carbamates] poisoning occurs because of inactivation of the enzyme acetylcholinesterase located in the neuromuscular junction, and is distinguished by single electrical stimulus induced repetitive responses and decrement response upon high rate repetitive nerve stimulation [RNS]. Oxime therapy with its action at different sites in the neuromuscular junction would alter the neuroelectrophysiological findings in acute anticholinesterases poisoning. The aim of this study is to evaluate the usefulness of RNS as a prognostic indicator of severity in acute anticholinesterase poisoning and the recovery process and its use as a guide for oxime therapy continuation or discontinuation. The study was conducted on 32 patients with acute organophosphorus poisoning admitted to the poison control center, Ain Shams University Hospitals during the period from January 2007 to June 2007. Patients were subdivided into group I [mild group n=6], group II [moderate group n=20], and group III [severe group n=6]. All the cases were clinically evaluated, pseudocholinesterase levels were estimated and RNS was done before and after oxime therapy. The patients were classified according to the decremental response into 3 categories, type 1 response [initial improvement and subsequent lack of improvement], type 2 responce [Initial improvement and subsequent normalization of neuromuscular transmission] and type 3 response [lack of improvement with initial dose of toxogonin]. RNS is a sensitive prognostic test which can be used as an early predictor of acute anticholinesterase poisoning for grading its severity, and assessment of obidoxime [Toxogonin] therapy. As therapeutic benefit of obidoxime is limited by its short duration of action, it is recommended to be administered for a longer period of time under neuroelectrophysiological guidance

Sleep apnea and its effect on ascitic patients

Obstructive sleep apnea syndrome has been recently described as a complication of ascites. This occurs due to elevated mechanical loads on the upper airway and defects in compensatory neuromuscular responses. Sleep disturbances, daytime hypersomnolence and neurocognitive dysfunction are common complications of cirrhosis and sleep apnea syndrome. The severity of these complications increases with the presence of both pathologies and improve markedly with the improvement of apnea after tapping of ascites. The aim of this study was to determine the type of apnea associated with ascites. The effect of apnea on the condition and the level of improvement in sleep disturbances and neurocognitive complications after tapping of ascites. The study was conducted on 40 patients with chronic liver disease, divided into 3 groups according to the extent of ascites. Group I with tense ascites [n=20], Group II with mild to moderate ascites [n=10], Group III without ascites [n=10]. Assessment was done through clinical examination, minimental state examination [MMSE], laboratory investigations, abdominal ultrasound and polysomnography. Sleep efficiency and neurocognitive functions as measured by MMSE were significantly affected with the increased degree of ascites. Apnea was found to be of the obstructive type. Apnea hypopnea index [AHI] was clearly higher in group I than groups II and III. MMSE and sleep efficiency showed a statistically significant correlation with the presence of significant apnea. AHI, sleep efficiency and MMSE improved markedly after tapping of ascites. Obstructive sleep apnea syndrome [OSAS] can be a complication of tense ascites. OSAS causes more deterioration of sleep efficiency and neurocognitive functions and these findings improved after tapping of ascites