Administration Of Anti-snake Venom Research Articles

Procurement and Supply of Anti Snake Venom as a Determinant of Snake Bite Management Outcome at a Government Medical College Hospital in Karnataka

International Journal of Medicine and Public Health,2017,7,1,47-50.DOI:10.5530/ijmedph.2017.1.8Published:March 2017Type:Original ArticleProcurement and Supply of Anti Snake Venom as a Determinant of Snake Bite Management Outcome at a Government Medical College Hospital in KarnatakaSiddaya Ramakrishna, and Puttamaligaiah Subhas Babu Siddaya Ramakrishna1, Puttamaligaiah Subhas Babu2 1Department of General Medicine, Mandya Institute of Medical Sciences, Mandya, Karnataka, India 2Department of Community Medicine, Mandya Institute of Medical Sciences, Mandya, Karnataka, India Abstract:Context: Snake bite poisoning, is an important reason for hospitalization and death in rural India. Availability and timely administration of anti snake venom (ASV) at hospitals is an important factor in favourable prognosis for snake bite victims. Aims: To determine i. proportion of venomous bites to non venomous bites ii. proportion of snake bite cases administered Anti snake venom iii. supply and utilization of Anti snake venom in one year period for treating snake bite victims Settings and Design: A Cross sectional, study was conducted in a Government Medical college hospital in Mandya, Karnataka from November 2012 to October 2013 to ascertain ASV utilization. Methods and Materials: Data was collected from hospitalized snake bite victims, from medico legal register (deaths) and in-patient records. Information on ASV stock and supplies, was obtained from the hospital main stores and ward indents. Statistical analysis used: Frequencies and Proportions. Results: 376 (n) snake bite cases were admitted to the hospital during the period, of which 77 victims (20.47%) had envenomation (including 4 deaths). Of 920 anti snake venom vials procured and supplied to the hospital, 915 vials were used, of which 531 vials (58.03%) were administered to those correctly diagnosed to have envenoming. 189 (50.13%) victims who were later diagnosed not to have envenoming, received 384 vials (41.97%). Conclusion: ASV utilization is complete and on a few occasions excessive. All cases of envenoming were not given 10 vials of ASV as suggested in the protocol. Some cases received 2 vials at admission and recovered. Keywords:anti-snake venom, envenoming, mismatch, stock, supply, UtilizationView:PDF (233.58 KB)

Anti-snake venom induced reactions among children with snake envenomation

Background: Snake envenomation in children is a neglected tropical condition with high morbidity and mortality. Life threatening neurotoxic and hemotoxic envenomation in children demands timely Anti Snake Venom (ASV) administration to improve the outcome.Methods: This was a prospective observational study undertaken at the pediatric intensive care unit of tertiary care referral center at Chengalpattu. All the 26 children with evidence of snake envenomation were recruited after informed consent of the caregivers during the study period. Clinical presentation and ASV related reactions were studied.Results: In this study of 26 children with envenomation, neurotoxic envenomation was more common. Foot was the common bite site. 10 of the 18 children (55.5%) had nocturnal bites. Ptosis, local swelling, hypotonia, headlag, vomiting and shock were the common clinical features. Polyvalent antivenom was used in all these children. ASV reactions of varying severity was encountered in 18 of the 26 children (69.2%). All the acute ASV reactions were encountered in the first 30 minutes. All the 18 children had rashes to begin with. Rashes and itching were the common feature of ASV reactions. Among children with reactions shock was seen in 50 %. Overall mortality was 3.85% (one child). None died due to anaphylaxis. The administration of ASV in primary and secondary centers was not carried out in time and the occurrence of anaphylaxis were not managed with inj adrenaline prior to referral. Inj pheniramine maleate, atropine and hydrocortisone were used by those centers. Referral after ASV reactions led to delay in completion of ASV administration.Conclusions: Occurence of ASV reactions is high in children (69%). There is an undue delay in ASV completion with ASV reactions. There is an urgent need for prevention of ASV reactions either by monovalent venoms or premedication prior to ASV administration.

Clinical profile & complications of neurotoxic snake bite & comparison of two regimens of polyvalent anti-snake venom in its treatment.

Background & objectives:The optimal anti-snake venom (ASV) dose required to treat neurotoxic snake envenomation is not known. Low-dose ASV (national protocol: maximum dose 200 ml) may be as efficacious as the conventional regimen (100 ml six hourly till all symptoms disappear), but a direct comparison of the regimens is not available. The aim of this study was to test the efficacy of low-dose ASV regimen against the conventional high-dose regimen.Methods:The clinical profile of 51 patients with neurotoxic snake envenomation was studied. Patients were treated with either the national protocol or the conventional protocol for ASV administration. The time to complete recovery of symptoms, duration of mechanical ventilation and total dose of ASV were compared.Results:More patients were females (28 vs. 23) bitten in the early morning hours (2400-0600 h). Thirty nine of 51 (76.4%) patients required mechanical ventilation. In terms of progression of neuroparalysis, time to complete resolution of ptosis and occurrence of VAP and ASV reactions, there was no difference. Duration of mechanical ventilation was less with the national protocol (24 vs. 43.5 h). Significantly less amount of ASV was used with the national protocol (224 vs. 982 ml) per patient. There were no mortality or permanent neurological sequelae with either regimen.Interpretation & conclusions:In this preliminary study, it was found that the national ASV protocol was as effective as the conventional regimen for neurotoxic snake bites. However, the findings need to be tested in a larger randomized controlled trial for definitive conclusions.

Comparative study of anaphylaxis incidence in patients receiving anti-snake venom with or without prophylactic adrenaline: a prospective, randomized, blinded study

Background: Anti-snake venom serum (ASV) administered for snake-bite patients is the most specific treatment available. Unfortunately, it can cause severe anaphylaxis which can be fatal sometimes. Methods: Fifty patients were included in the study and randomly divided into group A, who received sub-cutaneous adrenaline before administration of anti-venom serum and group B who did not. Each group comprised of twenty-five patients. The incidences as well as the severity of anaphylaxis in both groups and also the effects of subcutaneous adrenaline on the hemodynamic were analysed. Results: Anaphylactic reactions were significantly less in group A than group B population (p 0.05) implying that administration of sub-cutaneous adrenaline is safe. Conclusions: Prophylactic subcutaneous adrenaline before anti snake venom administration is highly efficacious and safe in reducing the incidence as well as severity of anaphylactic reactions.

Progressive Hemorrhage and Myotoxicity Induced by Echis carinatus Venom in Murine Model: Neutralization by Inhibitor Cocktail of N,N,N',N'-Tetrakis (2-Pyridylmethyl) Ethane-1,2-Diamine and Silymarin.

Viperbite is often associated with severe local toxicity, including progressive hemorrhage and myotoxicity, persistent even after the administration of anti-snake venom (ASV). In the recent past, investigations have revealed the orchestrated actions of Zn2+ metalloproteases (Zn2+MPs), phospholipase A2s (PLA2s) and hyaluronidases (HYs) in the onset and progression of local toxicity from the bitten site. As a consequence, venom researchers and medical practitioners are in deliberate quest of potent molecules alongside ASV to tackle the brutal local manifestations induced by aforesaid venom toxins. Based on these facts, we have demonstrated the protective efficacy of inhibitor cocktail containing equal ratios of N,N,N’,N’-tetrakis (2-pyridylmethyl) ethane-1,2-diamine (TPEN) and silymarin (SLN) against progressive local toxicity induced by Echis carinatus venom (ECV). In our previous study we have shown the inhibitory potentials of TPEN towards Zn2+MPs of ECV (IC50: 6.7 μM). In this study we have evaluated in vitro inhibitory potentials of SLN towards PLA2s (IC50: 12.5 μM) and HYs (IC50: 8 μM) of ECV in addition to docking studies. Further, we have demonstrated the protection of ECV induced local toxicity with 10 mM inhibitor cocktail following 15, 30 min (for hemorrhage and myotoxicity); 60 min (for hemorrhage alone) of ECV injection in murine model. The histological examination of skin and thigh muscle sections taken out from the site of ECV injection substantiated the overall protection offered by inhibitor cocktail. In conclusion, the protective efficacy of inhibitor cocktail is of high interest and can be administered locally alongside ASV to treat severe local toxicity.

Anti-Snake Venom (ASV) Induced Hypotension: An Emergent Complication of Treatment

Increased incidence of snake bites has been found, especially in coastal regions where tropical cyclones are very frequent. Anti-snake venom (ASV) is the only effective antidote and a snake bite victim is always vulnerable to its associated adverse reactions. It has to be used only in patients in whom the benefits of treatment are considered to exceed the risks of reactions. The present case was appropriate candidate for ASV administration and showed signs of improvement initially as seen in most such cases, but developed hypotension 24 hours later which persisted till the next 24 hours in spite of prompt management with dopamine and continuation of ASV. But it was seen that, following withdrawal of ASV on the third day the patient recovered. Therefore, such emergent reactions like hypotension can be avoided by cautious use and continuous monitoring of a patient on ASV.

English

It was always been a matter of great-controversy regarding the dosage protocol of anti- snake venom (ASV) in the management of snake envenomation. The only definitive treatment of poisonous snake bite is ASV administration. MATERIAL AND METHODS: This study was carried out for a period of two years. All patients of neuroparaplytic snake bite who presented to the emergency department were included in this prospectively study. RESULTS: Fifty eight patients of neurotoxic snake bite became eligible for the study over a period of 2 yrs. By using chi-square test, the outcomes in low and high bolus dose group were statistically non-significant (P>0.05). Statistical analysis showed no significant difference in both groups. From this study it can be firmly concluded that low dose ASV is as effective as high dose in treatment of neurotoxic snake bite.

Snakebite and severe hypertension: Looking for the Holy Grail

Sir The informative case report by Ahmed et al.[1] made us realize the clinical importance of elevated blood pressure in snake bite, recall pathogenesis, and revive educational aspects, based on our earlier experiences.[2] From the description made by the authors,[1] the offending snake in this report is likely to be krait. In developing countries where snakebites are ubiquitous, it is worth considering krait bite if pain abdomen precedes paralysis. The third “P” denotes potassium level, which invariably is low in many cases.[3] Also, in a given clinical setting with elevated BP in a child with a background history of paralysis following pain abdomen, without any renal manifestations or antecedent history of encephalitis, bulbar poliomyelitis, or Guillain Barre Syndrome, one has to include krait bite in the differential diagnosis. In addition to the reasons stated by the authors for elevated BP, other mechanisms are neuromuscular blockade at bulbar level, neurotoxin venom–induced release of catecholamines, decreased parasympathetic stimulation, and dysautonomia.[3] Slow recovery in this child.[1] may be attributable to delay in administration of anti snake venom and irreversible binding of venom to presynaptic receptor, as recovery occurs only with the generation of new neuromuscular junctions. Therapeutically though nitroglycerin infusion was beneficial, usefulness of angiotensin-converting-enzyme (ACE) inhibitors in hypertension due to snake bite was documented earlier.[4] Practitioners and emergency physicians have to avoid beta-blockers in snake venom–induced hypertension, as these agents are likely to precipitate severe alpha-agonist effects via the blockage of beta-receptor effects.[2] The mechanism for snakebite-induced hypertension, importance of recognizing this entity in acute-onset hypertension in the emergency room, differentiating this from other causes of secondary hypertension, and the need for administration of anti snake venom should be instilled in the minds of students of health sciences, and incorporated in teaching and training programs. Overall, early recognition and appropriate management with the anti snake venom and supportive measures not only save the patient[5] but also prevent further progression or deterioration of clinical status, since hypertension due to snake bite is completely reversible.

A retrospective review of snake bite victims admitted in a tertiary level teaching institute

Snake bite remains major public health problem worldwide. We present our experience with cases of snake bites managed in our tertiary care teaching center of South India. The details of all patients with snake bite admitted to a tertiary teaching care hospital from 2010 to 2012 were retrospectively retrieved and reviewed. The details regarding age, gender, first aid received or not, time elapsed between the bite, emergency care management and ASV (Anti Snake Venom) administration, site of snake bite, clinical features at the time of presentation, local examination findings at the site of bite, duration of hospital stay, need for elective ventilation, details of investigations and outcome were reviewed. The data were analyzed in PSPP software (Free Software Foundation, Inc.) for window for statistical analysis, while standard deviation (SD) was applied for the continuous variables, and proportions were applied for the categorical variables. Mean age was 38.4 ± 14.8 years (range 4-70 years). Majority [72 (82.8%)] were farmers. In 86.2% patients, the site of bite was in lower limbs. Snake could be identified in only 20 cases [Cobra-12 (60%), Krait-2 (10%), and Viper-6 (30%)]. Mean time to reach to hospital was 12.1 ± 21.4 hours (range 1-120 hours). Mean anti-venom therapy duration was 3.2 ± 2.0 days (range 1-14 days). Mean hospital stay was 4.7 ± 3.1 days (range 1-15 days). Majority (72.4%) made good recovery; mortality was in 4.6% cases, and 20 (23%) patients left against medical advice. This study identified major epidemiological and management variables related to snake bite. There is a need for a well-planned data collection and information dissemination system to avoid this potentially preventable disease.

Management of snake bite victims in a Tertiary Care Intensive Care Unit in North India.

Sir, We read with interest the clinical profile and manifestations of snakebite patients from a Medical College in Rural Area of Himachal Pradesh.[1] We would like to share our experience and emphasize on the different management regimes being followed world over. Twenty-five cases of snake bite were admitted in our Intensive Care Unit (ICU) from October 2012 to September 2013; three-fourth of them presented from June 2013 to September 2013. Patients with fang marks and swelling, cellulitis, bleeding, and blisters formation at the local site were included; any patient with suspicion of snake bite but no direct evidence was excluded. Mean age was 31.16 years (range: 13-70 years) and male to female ratio was 18:4. All patients presented with neuroparalytic features and reported of snake bite in the night during sleep. The mean duration of the ICU stay was 4.32 days (range: 3-13 days). The mean dose of equine polyvalent antisnake venom (ASV) administered was 48.63 vials (range: 40-60 vials). No patient had any adverse reactions to the antivenom. No other complication, namely acute renal failure, acute respiratory distress syndrome, cortical venous thrombosis or disseminated intravascular coagulation was reported during hospitalization. They were mechanically ventilated for a mean period of 3.18 days. Dose of ASV used by Raina et al.[1] was 292.69 ml ± 196.27 ml (range: 50-950 ml) which is 6 times higher than that reported in our series. They have thus reported allergic reactions in 7% of patients. Test doses have not been shown to have predictive value in predicting anaphylactic reaction or late serum sickness and are not recommended neutralizing power of antivenoms varies from batch to batch and this may be partially responsible for the difference. National Snakebite Management Protocol prepared by Ministry of Health and Family Welfare, India clearly defines the dose and routes of administration of ASV.[2] The recommended initial dose of ASV is 8-10 vials administered via intravenous route over a period of 1 h. Repeat doses for hemotoxic species is based on the 6 h rule; maximum recommended dose is 30 vials. Repeat doses for neurotoxic is based on the 1-2 h rule; maximum dose is 20 vials. Only the lyophilized polyvalent ASV is available in India. Anticholinesterase drugs have a variable, but potentially useful effect in patients with neurotoxic envenoming. Atropine sulfate (0.6 mg for adults; 50 μg/kg for children) followed by neostigmine in a dose range of 0.01-0.04 mg/kg every 1-3 h up to a maximum of 10 mg/24 h can be administered by intramuscular or intravenous route. Patients are observed over 30-60 min for improved neuromuscular transmission. Neostigmine appears to have no useful role in confirmed presynaptic envenoming, that is poisoning by common kraits and Russell's viper. It is effective in postsynaptic neurotoxins such as those of cobra.[3]“anticholinesterase test” (e.g. “tensilon test”) needs to be performed first to check responsiveness of the patient to the drug as is performed for patients with suspected myasthenia gravis. The use of these drugs will help reduce the consumption of ASV, which is generally limited in a developing country like ours.[4] Awareness of the health care providers on this issue needs to be increased and comparative trials need to be done to quantify its dose sparing effect.

Snake bite poisoning: A neglected life-threatening occupational hazard

Snake bite poisoning: A neglected life-threatening occupational hazard

A rare case of acute pancreatitis following snake envenomation with fatal outcome

The case study herein reported depicts a case of neurotoxic envenomation with common krait (Bangarus caeruleus) in a young farmer from a small village in India, which was unexpectedly complicated with acute pancreatitis. Patient developed features of acute abdomen on the third day of envenomation, and based on the laboratory and radiological findings, acute pancreatitis was diagnosed. Subsequently, consumptive coagulopathy, renal failure, and respiratory insufficiency set in. Despite timely administration of anti-snake venom and supportive treatment including hemodialysis, fresh frozen plasma and thrombocyte transfusion, and mechanical ventilation, the patient succumbed to severe toxemia of pancreatitis on the seventh day of envenomation. Pancreatitis associated with snake bite is an exceptional complication, and hence, we report this case on account of its rarity.

Hypertensive encephalopathy following snake bite in a child: A diagnostic dilemma

Children in rural India are a vulnerable group for snake bites. Improper elicitation of history and atypical presentations could lead to misdiagnosis and delay in treatment. We are reporting the case of an 8-year-old male child who presented with convulsions, unconsciousness and hypertension who was initially managed as a case of hypertensive encephalopathy showing no sign of improvement even after 20 hs. The history when reviewed suggested neurotoxic snake bite although the patient did not have any classical local findings. Anti-snake venom administration was followed by prompt recovery. We therefore suggest that snake bite should be considered in patients from rural background presenting with hypertension, convulsion and unconsciousness, even in the absence of classical features of snake bite.

Early Prediction of Acute Kidney Injury by Clinical Features of Snakebite Patients at the Time of Hospital Admission

Background:Snakebite is a major health problem in India. Venomous snakebite, which is an important medical hazard in several tropical countries including India, affects thousands of people per year and some of them develop acute kidney injury (AKI).Aims:This study was performed to find out 1) early clinical predictors for acute kidney injury in snakebite patients at the time of hospital admission and 2) incidence of acute kidney injury in snakebite patients.Materials and Methods:171 consecutively admitted non-diabetic, non-hypertensive snakebite patients were examined. Multivariate linear regression analysis with 95 percent confidence interval (CI) was done for statistical analysis. Analyses were performed by software Statistical Package for the Social Sciences (SPSS) (17th version for Windows).Results:Incidence of acute kidney injury was 43.27%. Development of acute kidney injury was independently associated with 20 min whole blood clotting test (20 min WBCT) (P value = 0.029; CI 95%), dark or brown color urine (P value = 0.000; CI 95%), and time interval between snakebite and anti-snake venom administration (P value = 0.000; CI 95%). Age (P value = 0.011; CI 95%) and presence of neurological signs (P value = 0.000; CI 95%) were negatively correlated with development of acute kidney injury.Conclusion:Incidence of acute kidney injury is slightly higher in our study than previous studies. Early prediction of acute kidney injury development in snakebite patients can be done by presence of black or brown urine, 20 min WBCT > 20 min, and increased time interval between snakebite and administration of anti-snake venom at the time of hospital admission. Young age group of snakebite patients develops acute kidney injury more commonly.

Do herbal medicines have potential for managing snake bite envenomation?

Snake envenomation is a global public health problem, with highest incidence in Southeast Asia. Inadequate health services, difficult transportation and consequent delay in antisnake venom administration are the main reasons for high mortality. Adverse drug reactions and inadequate storage conditions limit the use of antisnake venom. The medicinal plants, available locally and used widely by traditional healers, therefore need attention. A wide array of plants and their active principles have been evaluated for pharmacological properties. However, numerous unexplored plants claimed to be antidotes in folklore medicine need to be studied. The present article reviews the current status of various medicinal plants for the management of snake bite.

Clinical profile of venomous snake bites in north Indian military hospital

Snakebite is an environmental hazard associated with significant morbidity and mortality. We report a case series of venomous snakebites in a military operational area of north India. Of 33 cases of snake bites presenting to the military hospital, 21 patients were envenomated. The median age of patients was 24 years; all were men. All of the envenomations were neurotoxic in nature. Abdominal pain (91%), headache (86%), dysphagia (86%), ptosis (77%), diplopia (72%), blurred vision (72%), dyspnea (67%), and vomiting (62%) were the predominant clinical presentation. Polyvalent AntiSnakeVenom (ASV) [mean 180 ml; range 90-320 ml] was given to all patients with systemic manifestations, and repeated as needed. Eleven (52%) patients received neostigmine with glycopyrrolate to counter cholinergic effects. Two patients were given ventilatory support. The average time of recovery from envenomation was 16 hours after administration of ASV. All patients recovered without sequelae. Soldiers during military exercise are vulnerable to snakebites. Neurotoxic snakebites predominate in our study and usually present with autonomic features along with headache, abdominal pain, ptosis, diplopia and dysphasia. Preventive measures to minimize snake bites and planned treatment regimens should be emphasized among medical and military personnel deployed in the field operations.

Profile of snakebite envenoming in western Maharashtra, India

Ninety-one cases of snakebite were admitted between January 1998 and January 2001 to the general hospital at Mahad, 180 km south of Mumbai in western Maharashtra, India. Twenty-nine (31 · 9%) patients, when admitted to hospital, brought the snakes responsible for the bites (20 kraits, 9 Echis carinatus. Forty-five (49 · 5%) patients had snakebite without envenoming; 27 patients had local fang marks without local and systemic manifestations; 18, reporting 24 h after the bite, had local oedema. Twenty-six (28 · 6%) patients were paralysed. Twenty-five cases who reported between midnight and 08:00 showed no local signs of envenoming. One patient, who reported at 16:00, had local oedema with blebs and a history of cobra bite. Ten (11 · 0%) patients died: 3 on the way to hospital and 7 during treatment. Out of 7 cases transferred for tertiary care, 6 recovered and 1 died on the way to Mumbai. Early administration of anti-snake venom (ASV), endotracheal intubation and timely intervention with manual ventilation by Ambu bag and anticholinesterase treatment for Elapidae (krait and cobra) envenoming are crucial for saving lives. Clinical confirmation of snakebite with envenoming was by identification of the dead snake brought by victims and by clinical signs and symptoms such as paralysis (krait and cobra) and rapid progressive local oedema with active bleeding ( E. carinatus and Russell's viper). The 20-min whole blood clotting test is a simple, rapid and reliable test of coagulopathy. It is also of use in assessing the effectiveness of ASV and is of crucial importance for controlling administration of expensive ASV in relation to restoration of blood coagulability.

Correlation of renal status with hematologic profile in viperine bite.

Viper venom is mainly hemotoxic and causes coagulation disorders. One of the serious complications of viperine bite is renal failure. Forty adult cases of viper bite with systemic envenomation were studied for renal abnormality. Renal involvement was noted in 13 (32.5%) cases, of which eight (61.5%) had primary fibrinogenolysis and five (38.5%) had disseminated intravascular coagulopathy (DIC). Eight cases (61.5%) with renal dysfunction had incoagulable blood, whereas five (38.5%) had mild coagulation abnormality; however, none of the cases with incoagulable blood who received polyvalent anti-snake venom (ASV) within 8 hr of being bitten developed renal abnormality. In the majority of cases (61.5%), renal dysfunction persisted for more than a week longer than coagulation defects despite adequate treatment. Two cases died. Renal biopsy done in three cases with renal dysfunction revealed acute tubular necrosis. We concluded that renal abnormality correlated well with the degree of coagulation abnormality when left untreated due to late arrival at the hospital. Early administration of ASV prevents renal damage however severe the coagulation abnormality. It appears that DIC is not the cause of renal dysfunction in all cases of acute renal failure, and direct toxicity caused by venom could be responsible for renal dysfunction in certain cases.