Effect of hemoperfusion on ChE activity and toxicant clearance in patients with organophosphorus poisoning / 中国基层医药

Objective To investigate the effect of hemoperfusion (HP) on the activity of ChE in blood ofpatients with organophosphorus poisoning,and its toxicant clearance effect.Methods From January 2017 to January 2019,60 patients with organophosphorus poisoning in Shengjing Hospital Affiliated to China Medical University were divided into observation group and control group according to random number table method , with 30 cases in each group.The control group was treated with routine treatment ,while the observation group was treated with HP on the basis of routinetreatment.Thetherapeuticeffectsof thetwogroupswerecompared.Results Thedurationof mechanical ventilation and conscious awakening in the observation group were (3.07 ±1.14) d and (1.42 ±0.37) d,respectively, which were significantly shorter than those in the control group [(4.15 ±1.22) d,(2.01 ±0.58)d](t=3.543, 4.697,all P<0.05).The dosage of atropine in the observation group [(252.57 ±28.44) mg] was significantly less than that in the control group [(282.61 ±29.82)mg](t=3.993,P<0.05).The activity of cholinesterase after 12 h and 24 h of treatment was significantly higher than those before treatment (all P<0.05).After 12 h and 24 h of treatment,the cholinesterase activities in the observation group were (1128.64 ±152.49) U/L and (1422.08 ± 184.68)U/L,respectively,which were higher than those in the control group[(912.73 ±144.61) U/L and (1165.32 ± 173.27)U/L](t=5.627,5.553,all P<0.05).After 1 d and 3 d of treatment,the concentrations of organophosphorus poisons in the observation group were (1.08 ±0.30) mg/L and (0.62 ±0.18) mg/L,respectively,which were significantly lower than those in the control group[(1.32 ±0.35)mg/L and (0.84 ±0.27)mg/L](t =2.852, 3.713,all P<0.05).The incidences of rebound ,intermediate syndrome and multiple organ failure in the observation group were 3.33％(1/30),6.67％(2/30) and 13.33％(4/30),respectively,which were lower than those in the control group［23.33％(7／30),23.33％(7／30),36.67％(11／30)］(χ2 ＝5.192,3.278,4.356,all P ＜0.05).Conclusion HP has obvious effect on the activity of ChE and the concentration of blood poisons in patients with organophosphorus poisoning.It is worthy of popularizing and applying in clinic.

Effect of hemoperfusion on ChE activity and toxicant clearance in patients with organophosphorus poisoning / 中国基层医药

Objective@#To investigate the effect of hemoperfusion (HP) on the activity of ChE in blood of patients with organophosphorus poisoning, and its toxicant clearance effect.@*Methods@#From January 2017 to January 2019, 60 patients with organophosphorus poisoning in Shengjing Hospital Affiliated to China Medical University were divided into observation group and control group according to random number table method, with 30 cases in each group.The control group was treated with routine treatment, while the observation group was treated with HP on the basis of routine treatment.The therapeutic effects of the two groups were compared.@*Results@#The duration of mechanical ventilation and conscious awakening in the observation group were (3.07±1.14) d and (1.42±0.37) d, respectively, which were significantly shorter than those in the control group[(4.15±1.22) d, (2.01±0.58)d](t=3.543, 4.697, all P<0.05). The dosage of atropine in the observation group[(252.57±28.44)mg]was significantly less than that in the control group[(282.61±29.82)mg](t=3.993, P<0.05). The activity of cholinesterase after 12 h and 24 h of treatment was significantly higher than those before treatment (all P<0.05). After 12 h and 24 h of treatment, the cholinesterase activities in the observation group were (1 128.64±152.49)U/L and (1 422.08±184.68)U/L, respectively, which were higher than those in the control group[(912.73±144.61)U/L and (1 165.32±173.27)U/L](t=5.627, 5.553, all P<0.05). After 1 d and 3 d of treatment, the concentrations of organophosphorus poisons in the observation group were (1.08±0.30)mg/L and (0.62±0.18)mg/L, respectively, which were significantly lower than those in the control group[(1.32±0.35)mg/L and (0.84±0.27)mg/L](t=2.852, 3.713, all P<0.05). The incidences of rebound, intermediate syndrome and multiple organ failure in the observation group were 3.33% (1/30), 6.67% (2/30) and 13.33% (4/30), respectively, which were lower than those in the control group[23.33% (7/30), 23.33% (7/30), 36.67% (11/30)](χ2=5.192, 3.278, 4.356, all P<0.05).@*Conclusion@#HP has obvious effect on the activity of ChE and the concentration of blood poisons in patients with organophosphorus poisoning.It is worthy of popularizing and applying in clinic.

Síndromes asociados a intoxicación por organofosforados: abordaje médico y fisioterapéutico en cuidado crítico / Syndromes Associated with Organophosphate Poisoning: Medical and Physiotherapy Approach in Critical Care / Síndromes associados a intoxicação por organofosforados: abordagem médica e fisioterapêutica em cuidado crítico

Resumen Introducción: El artículo reporta un caso clínico de intento suicida de un paciente con síndrome intermedio a causa de intoxicación por organofosforados. Para ello se analizó la historia clínica, los exámenes complementarlos y el estudio electromiográflco, y se realizó revisión no sistemática de la literatura. Presentación del caso: Se describe un caso diagnosticado en la unidad de cuidado intensivo, el cual presentó trastornos neuromotores, requerimiento de soporte ventilatorio con destete difícil y extubación fallida, así como el tratamiento médico y fisioterapéutico instaurado. Dentro del manejo de la intoxicación por organo-fosforados se incluye la descontaminación del tóxico, administración de atropina y pralidoxima, diagnóstico oportuno del síndrome intermedio y la prescripción de ejercicio terapéutico. El paciente recibió manejo interdisciplinario, logrando liberación de su condición crítica, pero con persistencia de debilidad muscular proximal; sin embargo, con el ejercicio alcanzó recuperación funcional de sus actividades básicas cotidianas. Conclusión: El panorama mundial de las intoxicaciones por sustancias químicas muestra que son causa de morbilidad y discapacidad importante. Los organofosforados son los plaguicidas más frecuentemente involucrados. Los síntomas y signos clínicos de este tipo de intoxicaciones se clasifican en manifestaciones colinérgicas, el síndrome intermedio y la neuropatía retardada.

Abstract Introduction: The article reports a clinical case of a suicide attempt of a patient with intermediate syndrome due to organophosphate poisoning. Researchers analyzed the clinical history and the complementary examinations and carried out an electro-myographic study and a non-systematic review of the literature. Case presentation: A diagnosed case is described in the unit of intensive care, which presented neuro-motor disorders, required ventilator support with difficult weaning and unsuccessful extubation, as well as the established medical and physiotherapeutic treatment. The management of organophosphate poisoning includes the decontamination of the toxic, the administration of atropine and pralidoxime, the diagnosis of the intermediate syndrome, and the prescription of therapeutic exercise. The patient received interdisciplinary management, achieving liberation from his critical condition but with the persistence of proximal muscular weakness; however, with the exercise, he accomplished functional recovery for basic daily activities. Conclusion: The global outlook of chemical substances poisoning shows that they are a cause of morbidity and significant disability. The organophosphates are the pesticides most frequently involved. The symptoms and the clinical signs of this type of intoxication are classified into cholinergic manifestations, intermediate syndrome, and delayed neuropathy.

Resumo Introdução: O artigo reporta um caso clínico de tentativa suicida de um paciente com síndrome intermeio a causa de intoxicação por organofosforados. Para isto, analisara-se história clínica, os exames complementários e o estudo eletromiográfico, e se realizou revisão não sistemática da literatura. Apresentação do caso: Descreve-se um caso diagnosticado na unidade de cuidado intensivo, o qual apresentou transtornos neuromotores, requerimento de suporte ventilatório com desmame difícil e extubação falhada, tanto como o tratamento médico e fisioterapéutico instaurado. Dentro do manejo da intoxicação por organofosforados se inclui a descontaminação do tóxico, administração de atropina e pralidoxima, diagnóstico oportuno da síndrome intermeia e a prescrição de exercício terapêutico. O paciente recebeu manejo interdisciplinar, conseguindo liberação de sua condição crítica, mas com persisténcia de debilidade muscular proximal; no entanto, com o exercício alcançou recuperação funcional de suas atividades básicas cotidianas. Conclusão: O panorama mundial das intoxicações por substâncias químicas mostra que são causa de morbilidade e deficiência importante. Os organofosforados são os pesticidas mais frequentemente envolvidos. Os sintomas e signos clínicos deste tipo de intoxicações classificam-se em manifestações colinérgicas, a síndrome intermeia e a neuropatia retardada.

A study of 50 cases of Organophosphorus poisoning and its complications

Background: In developing countries, the widespread use of organophosphorus compounds (OPCs) has been accompanied by increasing incidence of poisoning with these agents, both suicidal and accidental. This is attributed mainly to their easy availability, indiscriminate handling, storage and lack of knowledge about the serious consequences of poisoning. Of the various substance used for suicidal attempts in India, OPCs form a significant group. Since the clinical manifestation of OPC poisoning is diverse ranging from mild symptoms to fatal complications in the course of time, we need proper management of the situation. Materials and methods: We studied 50 patients of organophosphorus poisoning. We checked vital parameters, general examination and systemic examination. We also checked for various parameters on like cholinesterase level, complete blood counts, renal function test with electrolytes, liver function test. Results: In this study majority of patients fell in 20-30 years of age group with male predominance from lower and middle socio-economical class and most common reason was suicidal. Precipitating event were domestic problem, marital friction and financial problem. Most common clinical features were vomiting, miosis and giddiness. Majority of the patients belonged to mild grade. The average S.cholinesterase level was low as severity increases. More doses of PAM and atropine are required in severe poisoning. Most common complication was respiratory paralysis. Death was more in severe poisoning. Conclusion: OPC is one of the most common poisoning in India. Reason for poisoning is most commonly suicidal. It is common in male with low socio-economical class mainly due to domestic Janak Chokshi, Kothi Zuber Suleman, Bhavikkumar Prajapati. A study of 50 cases of Organophosphorus poisoning and its complications. IAIM, 2019; 6(1): 16-22. Page 17 problems, financial issue and unhappy married life. In patients of OP poisoning presenting symptoms and S.ChE level directly correlated with severity. Therapeutic required dose of PAM and atropine are different in different grade of severity. Survival amongst patients is definitely better if atropine and PAM are being given with Mechanical ventilator support in cases of respiratory insufficiency.

Clinical profile and outcome of intermediate syndrome in acute organophosphate poisoning

Background: Deaths by acute organ phosphorus poisoning is very common in rural India especially in people associated with agriculture sector. The present study was aimed to study the clinical characteristics of organ phosphorus compound (OPC) poisoning and to assess the associated factors related to the outcome (recovery/death) of intermediate syndrome (IMS).Methods: This is an observational study conducted on 40 patients showing features of intermediate syndrome at Poison center, Institute of internal medicine, Rajiv Gandhi Government General Hospital, Chennai. Detailed clinical examination was done on the day of admission and daily with close monitoring. All patients included under study will be treated with pralidoxime as per protocol, atropine as required and other supportive measures was provided. Mechanical ventilatory support was provided for patients in respiratory failure. Patients are followed up till the end point of outcome (recovered and discharged/death) that was correlated with type of compound, quantum of exposure, duration of IMS, serum cholinesterase and creatinine kinase levels and respiratory failure.Result: Patients of age group between 30-40 years are more affected. Males outnumbered the females and most of them are from agriculture sector (65%). Out of 40, on treatment and follow up 34 patients were recovered and 6 were died. Onset of intermediate syndrome ranges between days 2-4 following exposure and duration of symptoms was observed for 5� days. Methylparathion was the frequent compound associated with IMS in about 9 cases. Out of 40, 16 had respiratory failure and given ventilator support. Proximal muscle weakness was seen in about 38 patients as common symptom.Conclusion: The results of the present study concludes that factors such as mode of poisoning, onset of IMS, type of compound, PChE level are not correlated with the outcome of study. Duration of IMS, respiratory failure, ventilator associated pneumonia (VAP), ventilator support duration were associated with outcome of the study. Hence, early recognition of IMS and its associated respiratory paralysis is very important in patients affected with OPC toxicity to prevent morbidity and mortality rate.

Initial Laboratory Parameters and its Correlation to Intermediate Syndrome in Patients with Acute Organophosphate Poisoning

PURPOSE: The association of serial serum cholinesterase (SChE) activity and the occurrence of intermediate syndrome (IMS) in patients orally poisoned with organophosphate (OP) were investigated. In addition, other clinical and laboratory factors were assessed for their ability to predict the subsequent development of IMS. METHODS: A total of 114 patients presented to our emergency department with acute OP ingestion between 2007 and 2012 were enrolled in this prospective study. Of these patients, 67 who needed mechanical ventilation (MV) over five days were divided into the IMS group. The 47 patients weaned from MV within four days after admission, or who did not receive the assistance of MV, were placed in the non-IMS group. The level of SChE at admission, 48 hours, and 96 hours, at discharge after admission were checked. The APACHE II (Acute Physiology, Age, Chronic Health Evaluation II) score, the amount ingested, exposure route, gender, age, and the laboratory test results were collected. All statistical analyses were performed using the Statistical Package for the Social Sciences (version 20.0). RESULTS: The mean age of total enrolled patients was 53.7+/-17.9 years and 73 patients (64.0% of total patients) were male. There were 102(89.5%) patients who intentionally ingested the OP and the mean amount ingested was 102.5+/-64.9 mL. The mean time after patients sought medical care was 5.4+/-10.5 hours after ingestion. The level of SChE at admission was 1,586+/-796 U/L and the APACHE II score was 28.81+/-19.7. The arterial pH, bicarbonate and carbon dioxide pressure, and serum protein and albumin were significantly lower in the IMS group than the non-IMS group (p<0.001). In contrast, the serum amylase, lipase, and glucose were higher in the IMS group. The APACHE II score, serum albumin and amylase, arterial bicarbonate, and the SChE at 48 and 96 hours after ingestion were independent factors that predicted the occurrence of IMS in patients with OP poisoning. The rate of recovery was 86.6% in the IMS group and 100% in the non-IMS group (p<0.001). CONCLUSION: Patients with a higher APACHE II score and levels of serum amylase, and lower levels of serum albumin and arterial bicarbonate, may be associated with the occurrence of IMS. Furthermore, when SChE levels after 48 hours and 96 hours did not increase, compared with the level of SChE at admission, patients tended to show IMS.

Initial Laboratory Parameters and its Correlation to Intermediate Syndrome in Patients with Acute Organophosphate Poisoning

PURPOSE: The association of serial serum cholinesterase (SChE) activity and the occurrence of intermediate syndrome (IMS) in patients orally poisoned with organophosphate (OP) were investigated. In addition, other clinical and laboratory factors were assessed for their ability to predict the subsequent development of IMS. METHODS: A total of 114 patients presented to our emergency department with acute OP ingestion between 2007 and 2012 were enrolled in this prospective study. Of these patients, 67 who needed mechanical ventilation (MV) over five days were divided into the IMS group. The 47 patients weaned from MV within four days after admission, or who did not receive the assistance of MV, were placed in the non-IMS group. The level of SChE at admission, 48 hours, and 96 hours, at discharge after admission were checked. The APACHE II (Acute Physiology, Age, Chronic Health Evaluation II) score, the amount ingested, exposure route, gender, age, and the laboratory test results were collected. All statistical analyses were performed using the Statistical Package for the Social Sciences (version 20.0). RESULTS: The mean age of total enrolled patients was 53.7+/-17.9 years and 73 patients (64.0% of total patients) were male. There were 102(89.5%) patients who intentionally ingested the OP and the mean amount ingested was 102.5+/-64.9 mL. The mean time after patients sought medical care was 5.4+/-10.5 hours after ingestion. The level of SChE at admission was 1,586+/-796 U/L and the APACHE II score was 28.81+/-19.7. The arterial pH, bicarbonate and carbon dioxide pressure, and serum protein and albumin were significantly lower in the IMS group than the non-IMS group (p<0.001). In contrast, the serum amylase, lipase, and glucose were higher in the IMS group. The APACHE II score, serum albumin and amylase, arterial bicarbonate, and the SChE at 48 and 96 hours after ingestion were independent factors that predicted the occurrence of IMS in patients with OP poisoning. The rate of recovery was 86.6% in the IMS group and 100% in the non-IMS group (p<0.001). CONCLUSION: Patients with a higher APACHE II score and levels of serum amylase, and lower levels of serum albumin and arterial bicarbonate, may be associated with the occurrence of IMS. Furthermore, when SChE levels after 48 hours and 96 hours did not increase, compared with the level of SChE at admission, patients tended to show IMS.

The risk factors analysis of acute organophosphate poisoning intermediate syndrome and nursing countermeasures / 中国实用护理杂志

Objective To analyze the risk factors of acute organophosphate pesticide poisoning intermediate syndrome(IMS ),and discuss the corresponding nursing countermeasures. Methods From January 2007 to January 2011,50 cases of patients with acute organophosphate pesticide poisoning were collected as the research object.And we analyzed the risk factors of related intermediate syndrome. Results The incidence rate of acute organophosphate poisoning intermediate syndrome was 10.0％.IMS mainly occurred at age of 20～50 years old,rarely occurred at age of ＜20 and ＞50 years old.The incidence of IMS with oral intake was higher than respiratory poisoning and skin poisoning.The incidence of IMS caused by drugs of moderate toxicity was higher than drugs with high or low toxicity.The incidence of IMS patients who got atropinization within 2 hours was less than those without it.The incidence of IMS patients using aminoglycoside drugs was higher than those not using them. Conclusions Poisoning way,toxicity of toxicant,timely treatment,basic diseases,atropinization within 2 hours,and using aminoglycoside drugs can influence the condition and prognosis of intermediate syndrome caused by organophosphate pesticide poisoning.

Multiple unusual complications in a single patient with combined organophosphate-carbamate pesticide exposure.

Poisoning with organophosphate (OP) or carbamate (CM) pesticides is very common in India. These compounds are powerful inhibitors of acetylcholinesterase, causing accumulation of acetylcholine resulting in muscarinic and nicotinic effects. In addition, there are often direct CNS effects including headache, tremor, delirium, slurred speech, ataxia, and convulsions. Coma supervenes in the later stages. Apart from these, OP poisoning can also induce an “intermediate syndrome” (IMS) characterized by proximal muscle weakness and paralysis; a “delayed syndrome” (organophosphate-induced delayed neuropathy or OPIND) characterized by polyneuropathy and weakness of distal limb muscles; and neuropsychiatric disturbances (chronic organophosphate-induced neuropsychiatric disorder or COPIND). Other disorders have very rarely been reported, such as Guillain-Barre syndrome, Parkin-sonism, transient hepatic dysfunction, pancreatitis, vocal cord paralysis, etc. We report a case of combined organophosphate-carbam-ate poisoning with multiple complications, e.g., intermediate syndrome (IMS), delayed neuropathy (OPIND), and Parkinsonism. These complications are rare, and some of them to the best of our knowledge have not been reported so far.

Intermediate syndrome in organophosphorous poisoning.

One hundred and fifty three cases of Organophosphorous poisoning cases presented to Kasturba Hospital, Manipal, India during a 2 year period ( 2001- 2002), out of which 45 cases (29.4%) had features of Intermediate Syndrome. Largest number of victims were in the age group of 21-30 years (37.7%). Males predominated (71.1%). Methyl Parathion was the commonest compound (57.7%). Respiratory muscle weakness was the most common manifestation seen (84.4%). Mortality was 22.3%.

A Case of Intermediate Syndrome of Organophosphate Poisoning after Dermal Exposure / 대한산업의학회지

BACKGROUND: Organophosphate poisoning is one of the most common toxicologic emergencies in Korea. Acute organophosphate poisoning and delayed polyneuropathy by ingestion are well published. There have been several reports about intermediate syndrome in organophosphate poisoning by ingestion but few about intermediate syndrome via dermal route. CASE REPORT: We observed a 59-years-old male who had weakness of proximal limb muscles and respiratory muscles 2 days after dermal exposure by unidentified pesticide. The paralytic symptoms lasted up to 20 days but the delayed polyneuropathy did not develop. The patient needed mechanical ventilatory support for 2 weeks and had completely recovered from IMS 6 weeks later. Electrophysiological study was characterized by an axonal polyneuropathy pattern on the proximal limb muscles. Serum acetylcholinesterase level was below half of normal level. Clinical manifestations and electrophysiological study support the clinical diagnosis of intermediate syndrome. CONCLUSION: Intermediate syndrome is commonly developed by ingestion of organophosphate but, as in this case, dermal absorption can also lead to intermediate syndrome. More detailed history taking and close observation is needed for about 3 or more days after intoxication because of the risk of respiratory failure.

Two Cases of Respiratory Failure After Recovery of Cholinergic Crisis in Organophosphate Poisoning: The Intermediate Syndrome / 결핵

Respiratory failure is the most serious manifestation and usual cause of death in acute organophosphate poisoning, and is common in acute cholinergic crisis. But the respiratory failure may appear suddenly in a patient who is recovering from the cholinergic crisis, even while receiving conventional therapy. These are case report of 37 years old male and 24 years old female with intermediate syndrome in organophosphate poisoning. The two patients ingested organophosphate(fenthion and mixture of DDVP with chlorpyrifos respectively) incidentally and in a sucide attempt respectively. After apparent recovery from the cholinergic crisis with a conventional therapy but before the expected onset of delayed polyneuropathy , the respiratory failure appeared suddenly with a muscular weakness, affecting predominantly the proximal limb muscles, neck flexors, territories of several motor cranial nerves. The two patients needed mechanical ventilatory support and recovery from the intermediate syndrome was complete in both patients, although one subsequently developed hypoxic encephalopathy. The clinical manifestation and electrophysiologic study support the clinical diagnosis of intermediate syndrome. The syndrome carries a risk of death, because of respiratory paralysis, if not recognized early and treated adequatedly. Prompt endotrachial intubation and mechanical ventilatory support is the cornerstone of treatment of the intermediate syndrome. Therefore, all patient should be observed in a hospital for up to 5 days after poisoning.