Intoxicaciones con rodenticidas superwarfarínicos / Superwarfarin rodenticide poisoning

Introducción: en la actualidad existe utilización masiva de rodenticidas y su venta no está restringida al público. Las etiologías de intoxicación por estos agentes son variadas pudiendo ser de tipo intencional o accidental. Objetivo: analizar estudios realizados en torno a intoxicaciones con rodenticidas superwarfarínicos en humanos con el propósito de reunir información que oriente a un adecuado tratamiento. Metodología: se realizó una revisión integradora en las bases de datos electrónicas PubMed, TripDataBase, Cochrane, además de Google Scholar y SciELO, libros de divulgación científica, documentos de convenciones, páginas web de instituciones públicas, privadas y artículos vinculados a efectos, cuadro clínico y tratamiento de exposiciones a rodenticidas en seres humanos. Se analizaron los documentos y la información se organizó en tres temáticas: toxicidad de los rodenticidas superwarfarínicos, cuadro clínico y tratamiento médico, y rodenticidas no anticoagulantes disponibles en Chile. Resultados: la dosis tóxica mínima reportada en adultos es de 1 mg de principio activo; en pacientes pediátricos ingestas accidentales rara vez producen síntomas. Los síntomas se observan de forma tardía y su toxicidad es variable. El examen de elección es el International Normalized Ratio (INR) y se realiza en todo paciente con factores de riesgo presentes. El antídoto no se administra de forma profiláctica y la dosis se ajusta individualmente. Conclusión: en niños las ingestas accidentales no son riesgosas por lo que pueden ser observados en el hogar. Pacientes con ingestas masivas requieren controles de INR por meses por lo que es importante que posterior al alta médica exista una óptima coordinación con nivel primario de atención.

Introduction: Currently there is a widespread use of rodenticides, unrestricted to the public. The exposure to these agents may varied being intentional or accidental. Objective: To analyze studies about superwarfarin poisoning in humans, with the purpose of gathering information to guide proper treatment. Methodology: It was conducted an integrative review in the electronic databases PubMed, TripDataBase, Cochrane, Google Scholar and SciELO, science books (reference textbooks), convention documents, websites from public and private institutions and articles about the effects, clinical manifestations and treatment of human exposures to rodenticides. Documents were analyzed and the information organized into three themes: superwarfarin toxicity, clinical features and medical treatment, and non-anticoagulant rodenticides available in Chile. Results: In adults, the minimum dose reported to cause toxicity is 1 mg of active ingredient. In pediatric patients, accidental intakes rarely produce symptoms. The symptoms of poisoning are usually delayed and its toxicity is variable. The test of choice is International Normalized Ratio (INR) and it is performed in all patients with risk factors. The antidote must not be administered prophylactically and the dose is adjusted individually. Conclusions: Accidental intakes in children are not risky and they can be observed at home. Patients with massive intakes require INR monitoring for months so, it is important that an optimal coordination with primary care facilities still exists after medical discharge.

Interaction between Warfarin and the Herbal Product Shengmai-Yin: A Case Report of Intracerebral Hematoma

A 71-year-old man was stable on warfarin (2.25 mg daily) therapy with an international normalized ratio (INR) of 1.8-2.2 after a heart valve replacement surgery. Recently, he consumed the liquid-like herbal product called shengmai-yin (10 mL daily) against medical advice. Seven days after the daily consumption of shengmai-yin, he was admitted to the intensive care unit because of consciousness disturbance [Glasgow Coma Scale (GCS) score 7] with an INR of 5.08. Head computed topography revealed intracerebral hematoma in the left temporoparietal region. Both warfarin therapy and the herbal product were withdrawn. At the same time, therapy with intravenous vitamin K1 40 mg was started. On the second day of admission, craniectomy was performed to remove the intacerebral hematoma under general anesthesia. He remained confused and restless for 2 days, but then showed progressive recovery in the consciousness level as well as motor and verbal functions. Shengmai-yin contains herbal ingredients that can interact with warfarin. The Drug Interaction Probability Scale (DIPS) indicated that warfarin and shengmai-yin were highly probable causes of intracerebral hematoma. Patients on warfarin therapy should be discouraged from taking herbal medicines, especially preparations that are already known to have antiplatelet and antithrombotic effects.

Interaction between Warfarin and the Herbal Product Shengmai-Yin: A Case Report of Intracerebral Hematoma

A 71-year-old man was stable on warfarin (2.25 mg daily) therapy with an international normalized ratio (INR) of 1.8-2.2 after a heart valve replacement surgery. Recently, he consumed the liquid-like herbal product called shengmai-yin (10 mL daily) against medical advice. Seven days after the daily consumption of shengmai-yin, he was admitted to the intensive care unit because of consciousness disturbance [Glasgow Coma Scale (GCS) score 7] with an INR of 5.08. Head computed topography revealed intracerebral hematoma in the left temporoparietal region. Both warfarin therapy and the herbal product were withdrawn. At the same time, therapy with intravenous vitamin K1 40 mg was started. On the second day of admission, craniectomy was performed to remove the intacerebral hematoma under general anesthesia. He remained confused and restless for 2 days, but then showed progressive recovery in the consciousness level as well as motor and verbal functions. Shengmai-yin contains herbal ingredients that can interact with warfarin. The Drug Interaction Probability Scale (DIPS) indicated that warfarin and shengmai-yin were highly probable causes of intracerebral hematoma. Patients on warfarin therapy should be discouraged from taking herbal medicines, especially preparations that are already known to have antiplatelet and antithrombotic effects.

Korean Patients with Superwarfarin Intoxication and Their Outcome

This observational study aimed at evaluating recent superwarfarin intoxication of Korean patients. Ten patients were diagnosed as or highly suspicious for superwarfarin intoxication. Case report forms described by attending hematologists of the patients were collected and analyzed. Bleeding symptoms were varied among the patients. Patients uniformly showed prolonged prothrombin time (PT) and activated thromboplastin time (aPTT) with decreased activity of vitamin K dependent coagulation factors. Positive serum brodifacoum test results in 4 of 5 requested patients contributed to confirmatory diagnosis. Psychiatric interview revealed an attempted ingestion in one patient. High dose vitamin K1 therapy promptly corrected prolonged PT and aPTT, but hasty discontinuation caused repeated bleeding diathesis in 6 patients. Route of intoxication was unknown or not definite among 8 of 10 patients. Three patients had a possibility of environmental exposure considering their occupations: there might be intoxication by transdermal absorption or inhalation. Therefore, high dose and prolonged use of vitamin K1 therapy is necessary for effective detoxification. Further detailed investigation on environmental exposure and efforts to improve availability of the blood level test in clinic are requested.

La terapéutica con anticoagulante oral y las complicaciones hemorrágicas / Therapy with oral anticoagulants and hemorrhagic complications

Se incluyó en el estudio un total de 26 pacientes adultos tratados con anticoagulantes orales en el Instituto de Cardiología y Cirugía Cardiovascular, por presentar manifestaciones hemorrágicas. Hubo un predominio del sexo masculino (15 pacientes). La warfarina fue el anticoagulante más utilizado (65%). Las manifestaciones hemorrágicas fueron múltiples. Los resultados del tiempo de protrombina fueron superiores a 35 segundos y se presentó equimosis en todos los pacientes. La vitamina K1 fue el tratamiento de elección en la totalidad. Se ingresaron 6 pacientes (23 %) y se asociaron al tratamiento sangre y plasma frescos. Las manifestaciones hemorrágicas incluyeron: sangramiento intraabdominal en 2 (8%) que requirieron tratamiento quirúrgico, derrame pleural en l (4%), derrame pericárdico en 2 (8%) y hematuria en l (4%). Todos los pacientes tuvieron una evolución satisfactoria, después del segundo día de tratamiento.