Abstract
Essentials Russell's viper envenoming is a major health issue in South Asia and causes coagulopathy.We studied the effect of fresh frozen plasma and two antivenom doses on correcting coagulopathy.Fresh frozen plasma did not hasten recovery of coagulopathy.Low‐dose antivenom did not worsen coagulopathy. SummaryBackgroundRussell's viper (Daboia russelii) envenoming is a major health issue in South Asia and causes venom‐induced consumption coagulopathy (VICC).ObjectivesTo investigate the effects of fresh frozen plasma (FFP) and two antivenom doses in correcting VICC.MethodsWe undertook an open‐label randomized controlled trial in patients with VICC at two Sri Lankan hospitals. Patients with suspected Russell's viper bites and coagulopathy were randomly allocated (1 : 1) to high‐dose antivenom (20 vials) or low‐dose antivenom (10 vials) plus 4 U of FFP. The primary outcome was the proportion of patients with an International Normalized Ratio (INR) of < 2 at 6 h after antivenom administration. Secondary outcomes included anaphylaxis, major hemorrhage, death, and clotting factor recovery.ResultsFrom 214 eligible patients, 141 were randomized: 71 to high‐dose antivenom, and 70 to low‐dose antivenom/FFP; five had no post‐antivenom blood tests. The groups were similar except for a delay of 1 h in antivenom administration for FFP patients. Six hours after antivenom administration, 23 of 69 (33%) patients allocated to high‐dose antivenom had an INR of < 2, as compared with 28 of 67 (42%) allocated to low‐dose antivenom/FFP (absolute difference 8%; 95% confidence interval − 8% to 25%). Fifteen patients allocated to FFP did not receive it. Severe anaphylaxis occurred equally frequently in each group. One patient given FFP developed transfusion‐related acute lung injury. Three deaths occurred in low‐dose antivenom/FFP patients, including one intracranial hemorrhage. There was no difference in recovery rates of INR or fibrinogen, but there was more rapid initial recovery of factor V and FX in FFP patients.Conclusion FFP after antivenom administration in patients with Russell's viper bites did not hasten recovery of coagulopathy. Low‐dose antivenom/FFP did not worsen VICC, suggesting that low‐dose antivenom is sufficient.
Highlights
Snakebite continues to be a major health issue in the rural tropics, in resource-poor regions of Asia, Africa, and Latin America
Venom-induced consumption coagulopathy (VICC) is the most frequent serious complication, and can result in major hemorrhage and death [2], the less common neurotoxicity carries a higher risk of a fatal outcome [3]
We have recently shown that recovery of coagulopathy occurs over a period of 24–48 h in patients given 10 vials of antivenom [15]
Summary
Snakebite continues to be a major health issue in the rural tropics, in resource-poor regions of Asia, Africa, and Latin America. It is difficult to estimate the numbers of envenoming cases and deaths each year, these are in excess of half a million and tens of thousands, respectively [1]. The major clinical syndromes of snake envenoming are coagulopathy, neurotoxicity (paralysis), myotoxicity, local cytotoxicity/necrosis, and acute kidney injury. Venom-induced consumption coagulopathy (VICC) is the most frequent serious complication, and can result in major hemorrhage and death [2], the less common neurotoxicity carries a higher risk of a fatal outcome [3]. The majority of studies of FFP in VICC have been observational in nature [6–9]
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