Carbamate Poisoning Research Articles

Life-Saving Resin: Hemoperfusion's Role in Overcoming Acute Organophosphate and Carbamate Poisoning

Background: Acute poisoning from organophosphates and carbamates is a major public health concern. These poisons inhibit acetylcholinesterase, leading to severe clinical manifestations. Traditional treatments, such as atropine and oximes, often fall short in severe cases, necessitating alternative therapeutic approaches. Hemoperfusion, an extracorporeal blood purification technique, has shown promise in improving outcomes for poisoning cases. This study aimed to estimate the clinical outcomes of resin-based HOD in individuals with acute organophosphate and carbamate poisoning admitted to a South Asian tertiary care hospital. Methods: A prospective observational study was carried out involving 50 patients diagnosed with acute organophosphate (n=30) or carbamate (n=20) poisoning. Patients underwent standard treatment protocols, and eligible individuals received resin-based hemoperfusion. Data on demographic details, clinical outcomes, complications, and biochemical parameters were collected and analysed using SPSS version 25.0. Results: The study found an overall recovery rate of 84%, with 80% recovery in the organophosphate group and 90% in the carbamate group. The complication rate was 12%, and the mortality rate was 4%. Cholinesterase levels significantly increased post-hemoperfusion, with a mean rise of 600 U/L. Time to treatment was a significant predictor of positive outcomes (p=0.011). Conclusion: Resin-based hemoperfusion is effective in treating acute organophosphate and carbamate poisoning, significantly improving recovery rates and reducing mortality. Early intervention is crucial for optimal outcomes. This treatment modality should be considered a valuable component of poisoning management protocols, especially in resource-limited settings. Recommendations: Further research with larger sample sizes and randomized controlled trials is recommended to confirm these findings and explore additional factors influencing treatment outcomes. Implementation of resin-based hemoperfusion in standard treatment protocols for severe poisoning cases is advised to enhance patient care and survival rates. Keywords: Organophosphate poisoning, Carbamate poisoning, Hemoperfusion, Clinical outcomes

A Case Presentation in Management of Dysphagia and Dysarthria Caused due to Organophosphorus and Carbamate Insecticide Poisoning.

Organophosphorus and carbamate Insectiside is common in Asia-Pacific region consisting of 63% of the Global death. Organophosphorus and Carbamate poisoning can lead into different complications in the respiratory,digestive,neurological aspects and maybe fatal in certain cases.Besides medical management of the same,early rehabilitation is also required to manage different kinds of neurological aspects caused due to Organophosphorus and carbamate poisoning. The study was done to introspect the early intervention in swallowing and speech therapy in organophosphorus and carbamate poisoning individual,as a part of management besides medical intervention. A 19years old female reported to the hospital with history of consuming organophos and carbamate insecticide with the intention of self harming causing cardiac arrest and as diagnosed as Flaccid Dysarthria with Oro-Pharyngeal Dysphagia when assessed with diagnostic tools respectively. Early speech and swallowing intervention was provided and introspected using MASA which showed improvement in scores during the therapeutic intervention and was statistically analysed using linear regression analysis. The result showed the improvement in MASA scores (the slope of the best fit) andproved that MASA scores improved significantly (slope = 14.3, p < 0.05) over time as the therapy sessions proceeded. The regression model wasalso significant (p < 0.05). The motor-speech therapeutic intervention provided improvement in the kinematics of oro-motor skills along with improvement in intelligibility of speech. This study concludes that early intervention in managing speech and swallowing abilities in Dysarthria and Dysphagia is helpful besides medical intervention in such cases.

Efficacy and Safety of Glycopyrrolate in the Management of Organophosphate and Carbamate Poisoning: A Systematic Review.

There is a lack of evidence on the effectiveness of antidotes in the management of organophosphate and carbamate (OPC) poisoning. We aimed to review the efficacy and safety of glycopyrrolate in the management of OPC poisoning. Databases such as PubMed, Scopus, Embase, and Cochrane Library were extensively searched from inception to November 2022 and updated till October 2023. Interventional, observational, and descriptive studies assessing the efficacy and safety of glycopyrrolate administered in any dose, route, and duration for the management of OPC poisoning published in the English language were considered for this review. The treatment with any other regimen that did not include glycopyrrolate was regarded as the comparator. The survival, intensive care unit (ICU) days and ventilatory outcomes were considered efficacy outcomes, and adverse effects were considered safety outcomes. Suitable quality assessment tools were used to assess the risk of bias in the included studies. Two independent reviewers were involved in the study selection, data extraction, and quality assessment and any discrepancies were resolved through mutual discussion or consultation with a third reviewer. A total of 9 studies (2 RCTs, 4 cohorts, 1 case series, and 2 case reports) out of 591 nonduplicate records were considered for this review. Overall, the RCTs were observed to have a moderate quality, and observational studies and descriptive studies were found to have good quality. All the included studies used atropine administration as a standard treatment option along with glycopyrrolate. The OPC patients treated with glycopyrrolate had a fewer hospitalization days with comparable recovery and ventilatory outcomes than those that had not been treated with glycopyrrolate. The occurrence of adverse events and complications was lower in the glycopyrrolate group than in the control group. Currently, there is a lack of comparative studies to recommend the use of glycopyrrolate in OPC poisoning, and further interventional studies are required to make an evidencebased recommendation on this topic.

A Study on the Clinical Profile of Non-Organophosphorus Poisoning in a Tertiary Care Hospital

Poisoning is emerging as a very important global health issue particularly in agricultural countries like India. Although wide range of data is available on organophosphorus poisoning cases, studies and data are limited on non-organophosphorus compound poisoning like paraquat, rodenticide (zinc phosphide, yellow phosphorus, sodium monofluroacetate, fluroacetamide, arsenic, warfarins, and scilliroside etc.), pyrethroid, carbamate etc. The present study aims to study the clinical presentation and outcome of the non-organophosphorus poisoning cases. A cross sectional retrospective study was conducted at Assam Medical College and Hospital, Dibrugarh. In this study the data of the patients with nonorganophosphorus poisoning admitted to Assam Medical College from July, 2022 to July, 2023 were collected and analysed. A total of 104 patients were included in the study and most patients belonged to the age group of below 30 years. Out of all the cases highest number patients presented with Paraquat poisoning (48.1%), while distribution of other cases was as follows- Phenyl (12.5%), Pyrethroid (23.1%), Rodenticide (10.6%), Carbamate (1.9%) and Organochloride (3.6%). Vomiting was the most common presenting symptom. Hepatic and renal impairment was observed only in the paraquat poisoning cases and it was also associated with high mortality rate (88%). Acute Hepatitis and Acute kidney Injury was quite common among paraquat poisoning patients and mortality was mainly observed in paraquat, rodenticide and carbamate poisoning cases. Comprehensive care and awareness among general public is necessary for prevention and better management of poisoning cases. Development of proper rational management guidelines is also pivotal for reducing mortality in these cases.

Prognostication and Prediction of Outcomes in Patients with Organophosphorus and Carbamate Poisoning: A Prospective Cohort Study.

Organophosphorus (OP) and carbamate poisoning are significant concerns in developing nations. This study evaluates the effectiveness of the ChE check mobile, a cholinesterase-rapid bedside diagnostic test, in the diagnosis and management of OP and carbamate poisoning. We conducted this prospective observational study, involving patients with OP and carbamate poisoning over 1 year (June 2016 to June 2017) at a single tertiary care center. Levels of RBC cholinesterase (E-AChE), butyl cholinesterase (BChE), and various other determinants were systematically coded and analyzed. The study population (n = 60) consisted primarily of males (n = 43; 71.7%), with a mean age of 30.6 (SD: 13.7) years. Monocrotophos (n = 10; 20.4%) and carbofuran (n = 4; 8.1%) were the commonest OP and carbamate compounds, respectively. The median initial atropinization dose was 10 (IQR: 0, 61.5) mg, with a median total administered atropine dose of 116 (IQR: 32, 320) mg. A significant negative correlation was found between E-AChE levels and both the initial atropinization dose (ρ: -0.653, p-value < 0.001) and total atropine requirement (ρ: -0.659, p-value < 0.001) during admission. An E-AChE cut-off of 4 units/g hemoglobin provided an area under the curve of 0.73 (sensitivity: 80.0%, specificity: 68.6%, p-value < 0.001) for predicting moderate to severe peradeniya organophosphorus poisoning. The check mobile device can be a valuable tool for prognosticating patients. There was a significant correlation between low E-AChE levels and the atropine requirement and severity. Jha A, Hazra D, Yadav B, Zachariah A, Alex R. Prognostication and Prediction of Outcomes in Patients with Organophosphorus and Carbamate Poisoning: A Prospective Cohort Study. Indian J Crit Care Med 2024;28(2):141-147.

Association of Pesticide Exposure with Cognitive Function in Farmers

Introduction: Organophosphate and carbamate are two types of pesticides that can induce cholinesterase suppression in humans. These lead to poisoning symptoms including muscle paralysis and respiratory depression in acute settings. In chronic settings, the mechanism of organophosphate and carbamate poisoning is still openly discussed. Accordingly, this study aimed to identify any correlations between erythrocyte cholinesterase and type of pesticides with cognitive performance of the subjects. Methods: This cross-sectional study was conducted in two sampling periods (July 2017 and October 2018) in Ngablak Districts, Magelang Regency, Central Java, Indonesia. The study subjects were farmers with history of pesticide exposure. Cholinesterase levels (ChE) were analyzed from blood samples. Cognitive performance was assessed using the Mini Mental State Examination (MMSE) and Stroop Test. Results: In total, 151 subjects aged between 23 and 91 years old were included. The long-term organophosphate exposure group had significantly lower MMSE scores compared with other types of pesticides, but not in carbamate (p = 0.017). After comparing “organophosphate only” and “carbamate only” groups, there were significant differences in MMSE scores (p = 0.018) but not in blood ChE levels (p = 0.286). Detailed assessment in MMSE domains showed significantly lower scores for orientation, attention, and registration domains (p < 0.05) in the organophosphate group. There were no significant associations between types of pesticides and blood ChE levels with the Stroop Test results (p > 0.05). Conclusions: Long-term organophosphate exposure could produce lower cognitive function and the insignificant association between blood ChE levels to MMSE could lead to non-cholinergic pathways as its underlying pathology.

Epidemiology of carbamate poisoning in Brazil, from 2010 to 2020

Epidemiology of carbamate poisoning in Brazil, from 2010 to 2020

Hemoperfusion for Clinically Suspected Organophosphate and Carbamate Poisoning in Critically Ill Patients: A Randomized Trial

Introduction: Organophosphate poisoning occurs frequently, and despite treatment, increased severity and intensive care unit (ICU) admissions have been observed. We hypothesized that early hemoperfusion/hemadsorption (HA) therapy would change the clinical course of the disease. Methods: We performed a prospective, open, randomized controlled study at an academic ICU. Adult patients referred for an acute cholinergic toxidrome were screened. Patients meeting inclusion and exclusion criteria were randomized to standard of care (SoC) or HA therapy plus SoC, which included 2 6-h cycles of HA 12 h apart beginning within the first 24 h of ICU admission. The primary outcome was a comparison of ICU length of stay (LOS). Results: There were no significant baseline differences between the groups. The median ICU LOS was 6.5 days (IQR 4.5–10) in the HA group compared to 8 days (IQR 3.5–17) for the control group, p = 0.58. Among patients with an excess ICU LOS ≥7 days, the median ICU LOS was significantly shorter for the HA group, 10 days (IQR 8–12) compared to 17 days (IQR 14–22) for the control group, p = 0.001, resulting in a cost saving of EUR 7308 per patient. Duration (8 days vs. 13.5 days) and cumulative dosage (316 mg vs. 887 mg) of atropine among patients with excess ICU LOS were significantly lower in the HA group compared to the SoC group, respectively. A similar reduction in the duration of mechanical ventilation (HA = 6 days vs. SoC = 15 days, p = 0.001) was found. The combination of day 28 mortality and severe complications was lower in the HA group (10%, n = 2/20) compared to the SoC group (42%, 14/33) p = 0.01. Conclusion: HA therapy resulted in significant cost savings driven by a reduced LOS among patients with excess ICU LOS ≥7 days. This therapy was also associated with a significant reduction in the combination of day 28 mortality and severe complications including cardiac arrest, organ dysfunction, reintubation, and tracheostomy.

Laryngeal Dysfunction in Acute Organophosphorus and Carbamate Poisoning.

ABSTRACTBackgroundOrganophosphorus (OP) and carbamate pesticides are widely used for crop protection. We describe the spectrum of laryngeal abnormalities in patients admitted to the intensive care unit (ICU) with acute OP and carbamate poisoning as there is limited information on it.Materials and methodsConsecutive patients admitted to the ICU with acute OP and carbamate poisoning over 20 months (December 2014–July 2016) were recruited. Patients were followed up post-discharge if they had undergone tracheostomy or developed hoarseness of voice or stridor following extubation. Asymptomatic individuals who consented underwent laryngoscopy after ICU discharge. The primary outcome was the development of laryngeal dysfunction. Other outcomes included length of stay, need for ventilation, mortality, tracheostomy, and time to decannulation of tracheostomy.ResultsOf the 136 patients recruited, 71 (52%) underwent laryngoscopy. The overall mortality rate was 9.6%. Of the 71 patients who underwent laryngoscopy, 18 had abnormal findings, which included unilateral or bilateral vocal cord paresis or palsy (n = 14) and/or aspiration (n = 9), subglottic stenosis (n = 1), tracheal stenosis (n = 1), or arytenoid granuloma (n = 1). Laryngeal dysfunction was associated with the ingestion of a dimethyl OP compound (p = 0.04) and quantum consumed (p <0.001). Patients with laryngeal dysfunction had significantly (p = 0.004) longer hospital stay (19.1 ± 10.7 vs 11.8 ± 8.3 days).ConclusionLaryngeal dysfunction is not uncommon in OP and carbamate poisoning and is associated with the ingestion of larger quantity of a dimethyl OP compound and longer hospital stay. Otorhinolaryngologists could be involved early to help identify these abnormalities and initiate an appropriate treatment to ensure a functional voice and good airway.How to cite this articleMani GS, Mathews SS, Victor P, Peter JV, Yadav B, Albert RRA. Laryngeal Dysfunction in Acute Organophosphorus and Carbamate Poisoning. Indian J Crit Care Med 2022;26(2):167–173.

Incidence of organophosphate and carbamate poisoning in dogs within Maiduguri, North-eastern Nigeria

The persistent application of chemicals in pest control and agricultural processes possess a public health concern as their use are often associated with acute or chronic poisoning cases in both humans and animals. In veterinary medicine, pesticides such as organophosphates and carbamates are exclusively used in ectoparasitic control through pour on, tick bath and fumigation. The incidence of organophosphate or carbamate poisoning in dogs within Maiduguri, north-eastern Nigeria was assessed using three government approved and licensed veterinary centres. Data were obtained through the review of three years (2016-2018) retrospective cases of organophosphate/carbamate poisoning and administration of questionnaires to actively practising veterinarians. Investigation revealed that organophosphate/carbamate poisoning in dogs within Maiduguri metropolis constituted 37% of poisoning cases and was on the increase in recent years with 22.96% of the total cases reported in 2016, 34.08% in 2017 and 42.96% in 2018. The case was most prevalent at the peak of the rainy season around July and August. The common clinical signs observed include salivation, vomiting, diarrhoea, muscle spasms, severe weakness and paralysis. Management was usually supportive and symptomatic while antidotal therapy revolved on atropine sulphate only. The effect of ageing in organophosphate poisoning was neglected by most of the clinicians as more than 50% would administer atropine sulphate without considering the duration of the onset of poisoning. It was concluded that the incidence of organophosphate and carbamate poisoning in dogs in Maiduguri constituted 37% of all poisoning cases where 22.96% and 42.96% of it were reported in 2016 and 2018, respectively. Enlightenment programmes for the public and professionals are recommended on the increased cases of poisoning and proper use of antidote in the treatment of chemical toxicosis.

Selected Liver Markers in Predicting the Severity of Organophosphate and Carbamate Poisoning.

Background Intentional ingestion of organophosphate (OP) and carbamate is a significant health issue worldwide. It causes adverse health effects on the liver. This study aimed to determine liver transaminases (AST and ALT) and bilirubin levels to assess the severity of poisoning in patients with acute OP and carbamate poisoning. Methods A descriptive cross-sectional study was conducted on patients admitted to a selected hospital in Sri Lanka with acute OP and carbamate poisoning. The severity of poisoning was measured by RBC cholinesterase and Peradeniya Organophosphorus Poisoning scale (POP), where six clinical features were assessed based on a 3-point scale. A score of 0–3 was considered mild, 4–7 to be moderate, and 8–11 to be severe poisoning. Liver parameters such as AST, ALT, and total and direct bilirubin were measured. Results Among the 188 screened patients, 166 were recruited. Majority were males (112, 67.5%). Kruskal–Wallis test showed significant differences in AST and ALT on admission and AST on discharge, across POP groups ((χ2 (2, n = 166) = 26.48, p ≤ 0.001), (χ2 (2, n = 166) = 14.31, p=0.001), and (χ2 (2, n = 157) = 11.34, p=0.003), respectively)). Mann–Whitney U test showed significantly higher AST and ALT in the moderate POP group compared to the mild POP group (AST: U = 1709, z = −4.50, p ≤ 0.001, r = 0.36; ALT: U = 2114, z = −3.04, p=0.002, r = 0.26) on admission. In addition, the treatment outcomes (duration of hospital stay and duration of ventilator assistance) were significantly correlated (p ≤ 0.001) with the severity of poisoning and serum AST and ALT at the time of admission. Conclusion AST and ALT levels on admission and AST level at discharge showed significant correlations with the severity of poisoning. Treatment outcomes significantly correlated with the severity of poisoning and serum AST and ALT levels.

Pesticide-induced changes in cholinesterase activity and chronic kidney disease of unknown etiology among farmers in Nakhon Ratchasima, Thailand

Chronic kidney disease of unknown etiology (CKDu) has emerged agricultural population. This study aimed to obtain a prevalence of cholinesterase activity and CKDu, and evaluate factors associated with organophosphate (OP) and carbamate (CA) poisoning and CKDu among farmers in Nakhon Ratchasima province, Thailand. A cross-sectional study was conducted among 58 farmers, with data collected using a structured questionnaire. Blood and urine samples were collected for analysis of erythrocyte acetylcholinesterase (AChE), butyrylcholinesterase (BuChE), serum creatinine (SCr), and urinary creatinine (UCr). Farmers who had CKD without diabetes, hypertension, proteinurea, and other traditional causes were classified as CKDu. The average age (± SD) was 49.22(± 6.87) years. The prevalence of abnormal AChE and BuChE activity levels were 55.17% and 46.55%, respectively. In kidney function, the prevalence of abnormal UCr was 17.24% and CKDu was 24.14%. In adjusted model, the type of pesticide sprayer and personal protective equipment used were significantly associated with CKDu (bivariate analysis, p < 0.05). Using multivariate analysis, OP and CA poisoning were significantly associated with a 4.703-fold higher risk of CKDu (95% CI = 1.020-21.686). Farmers who applied OP and CA pesticides had decreased kidney function. These findings might be beneficial in reducing the adverse effects pesticide exposure and CKDu prevention.

A study profile of deaths due to carbamate poisoning and its management in Hyderabad region

Introduction: Poisoning with various substances is an important cause of death and disability worldwide. The types of poisons that are encountered in the emergency medicine departments encompass a wide range of substances. Apparently, geographic location, socio-demographic factors, ease of availability of poisons and many other cryptic factors contribute to the wide spectrum of substances that cause poisoning. Pesticides, drugs and chemicals are reported to be the most commonly used poisons in India. Management of poisoning is quite challenging for the health care professionals globally. Factors such as the uncertainty in the identification of allegedly consumed poison, varied clinical features and the need for timely access to specific information for treatment, complicates poisoning management. Aim: This study was therefore conducted to explore the clinical features, management and outcomes of poisoning cases reporting to a tertiary care centre in Hyderabad. Methods & Results: The present study was undertaken to evaluate the pattern of poisoning deaths in Hyderabad region of Telangana. The Paper presents the study of 271 cases of poisoning during the span of three years from 01/04/2016 to 31/03/2018. Out of 1841 Post mortem examination done during the study period 271 cases were of poisoning. Among the poison cases carbamate insecticide accounted for 21 cases (7.74%). The cases were then analyzed on various parameters in the pro forma prepared for this purpose. We concluded that majority of victims were married, different religions males from rural area and low socioeconomic group. The incidence of poisoning was more common during 21-30years of life. Suicidal cases were more common than accidental cases. Few case of homicidal poisoning was detected in present study, chemical analysis of viscera done in cases. Conclusion: Carbamate poisoning was the most common type of poisoning. Several chemicals like Lannate, Baygon, Temik, Sevian and Isolanwere used with sui

Impact of Acid-Base Status on Mortality in Patients with Acute Pesticide Poisoning.

We investigated clinical impacts of various acid-base approaches (physiologic, base excess (BE)-based, and physicochemical) on mortality in patients with acute pesticide intoxication and mutual intercorrelated effects using principal component analysis (PCA). This retrospective study included patients admitted from January 2015 to December 2019 because of pesticide intoxication. We compared parameters assessing the acid-base status between two groups, survivors and non-survivors. Associations between parameters and 30-days mortality were investigated. A total of 797 patients were analyzed. In non-survivors, pH, bicarbonate concentration (HCO3−), total concentration of carbon dioxide (tCO2), BE, and effective strong ion difference (SIDe) were lower and apparent strong ion difference (SIDa), strong ion gap (SIG), total concentration of weak acids, and corrected anion gap (corAG) were higher than in survivors. In the multivariable logistic analysis, BE, corAG, SIDa, and SIDe were associated with mortality. PCA identified four principal components related to mortality. SIDe, HCO3−, tCO2, BE, SIG, and corAG were loaded to principal component 1 (PC1), referred as total buffer bases to receive and handle generated acids. PC1 was an important factor in predicting mortality irrespective of the pesticide category. PC3, loaded mainly with pCO2, suggested respiratory components of the acid-base system. PC3 was associated with 30-days mortality, especially in organophosphate or carbamate poisoning. Our study showed that acid-base abnormalities were associated with mortality in patients with acute pesticide poisoning. We reduced these variables into four PCs, resembling the physicochemical approach, revealed that PCs representing total buffer bases and respiratory components played an important role in acute pesticide poisoning.

Carbamate Poisoning – An Autopsy Study

Acute poisoning is a cause of both morbidity and fatality in many parts of the world. Furadan, the organocarbamatecommonly available in Kerala, being used in plantain, tea, potato and carrot farms as insecticideare usually misused as an easy source of poison for suicide. This study was carried out on Twenty ninemedico legal cases, brought with history of carbamate poisoning which were brought for autopsy duringthe period from January 2014 to June 2015. The main objectives of the study were to study post-mortemfindings in Carbamate poisoning, clinical profile in Carbamate poisoning and histopathological changes inBrain, Heart, Lungs, Liver and Kidney due to Carbamate poisoning. Males (82.8%) outnumbered femalesand maximum cases were of age group 51-60 yrs (27.6%). Most of the victims were taken to hospitalfor treatment and died after admission (58.6%). Such studies of poisoning cases will help authorities forplanning, prevention and treatment of these cases

Assessment and Methods of Nutritional Support during Atropinization in Organophosphate and Carbamate Poisoning Cases

Purpose: Atropine is an antidote used to relieve muscarinic symptoms in patients with organophosphate and carbamate poisoning. Nutritional support via the enteral nutrition (EN) route might be associated with improved clinical outcomes in critically ill patients. This study examined the administration of nutritional support in patients undergoing atropinization, including methods of supply, outcomes, and complications. Methods: A retrospective observational study was conducted in a tertiary care teaching hospital from 2010 to 2018. Forty-five patients, who were administered with atropine and on mechanical ventilation (MV) due to organophosphate or carbamate poisoning, were enrolled. Results: Nutritional support was initiated on the third day of hospitalization. Thirty-three patients (73.3%) were initially supported using parenteral nutrition (PN). During atropinization, 32 patients (71.1%) received nutritional support via EN (9) or PN (23). There was no obvious reason for not starting EN during atropinization (61.1%). Pneumonia was observed in both patient groups on EN and PN (p=0.049). Patients without nutritional support had a shorter MV duration (p=0.034) than patients with nutritional support. The methods of nutritional support during atropinization did not show differences in the number of hospital days (p=0.711), MV duration (p=0.933), duration of ICU stay (p=0.850), or recovery at discharge (p=0.197). Conclusion: Most patients undergoing atropinization were administered PN without obvious reasons to preclude EN. Nutritional support was not correlated with the treatment outcomes or pneumonia. From these results, it might be possible to choose EN in patients undergoing atropinization, but further studies will be necessary.

Adrenaline is effective in reversing the inadequate heart rate response in atropine treated organophosphorus and carbamate poisoning

Background In acute organophosphorus (OP) or carbamate poisoning, some patients require high dose atropine to counteract the effects on heart rate (HR) and blood pressure (BP). This study describes the factors associated with high dose atropine therapy and the use of adrenaline to reverse the inadequate HR response to atropine. Methods Consecutive patients admitted to the intensive care unit (ICU) were prospectively recruited. Demographic data, treatment and outcomes of patients who failed to achieve target HR (100/min) or systolic BP >90 mm Hg with either a cumulative atropine dose of 100-mg within 6-h following admission or an infusion of 30 mg/h for at least 3-h were compared with patients who achieved the targets. Factors associated with high dose atropine therapy were explored using logistic regression analysis and expressed as odds ratio (OR) with 95% confidence intervals (CIs). Results Of the 181 patients admitted with OP or carbamate poisoning, 155 patients fulfilled inclusion criteria. The mean (SD) age was 35.7 (15.8) years; admission APACHE-II score was 14.6 (7.5). Heart rate and/or BP target was not achieved in 13.6%. In these patients, target HR was achieved after adding adrenaline infusion at 2–4 μg/min. Ventilation duration (11.6 ± 6.3 vs. 8.4 ± 6.9 days, p = 0.05) and ICU stay (12.3 ± 5.8 vs. 8.9 ± 5.8 days, p = 0.01) were longer in patients requiring high dose atropine when compared with others. On multivariate logistic regression analysis, shorter time to presentation to hospital (p = 0.04) was associated with need for high dose atropine. Overall mortality was 9% and similar in both groups (p = 0.41). Conclusions High dose atropine therapy is required in a subset of patients with OP and carbamate poisoning and was associated with longer ventilation duration and ICU stay. Adrenaline infusion improved hemodynamics in these patients.

The role of oximes in the management of acute poisoning with cholinesterase inhibitors pesticides: Case reports

Acute pesticides poisonings is a serious public health problem in Algeria. The indication of oximes in the treatment of poisoning by cholinesterase inhibitors pesticides is still controversial in practice, although it seems theoretically interesting because of the reversibility of the toxic-cholinesterase binding and the atropine-like effect. The interest of oximes in the management of cholinesterase inhibitors pesticides poisoning will be discussed through the study of the observation of 4 patients received at University Hospital Center of Oran (Algeria). Observations and discussion The study of the 4 observations enabled us to highlight the following points. For collapsed cholinesterase activity levels, it is better to administrate the highest recommended doses of Pralidoxime immediately, this will allow a rapid regeneration of an important fraction of inhibited cholinesterase activity, process which is concentration-dependent. Early intake of Pralidoxime with continuous injections appeared to have resulted in a rapid and favourable evolution. The use of oximes in carbamate poisoning is still debatable and needs further research. In view of the data presented, oximes retain their place in the treatment of acute intoxication with cholinesterase inhibitors. Their indication should be discussed for each case taking into account the anamnesis, clinical presentation and level of cholinesterase activity.

Atropine Refractoriness in Acute Organophosphorus and Carbamate Poisoning

Background: In acute Organophosphorus (OP) or Carbamate poisoning, some patients require high dose atropine to achieve atropinisation targets. This study evaluated the incidence and factors associated with atropine refractoriness. Methods: Consecutive patients, admitted to the intensive care unit (ICU) with OP and Carbamate, were prospectively recruited. Atropine refractoriness was defined as failure to achieve target heart rate (100/min) or systolic BP >90 mm Hg with either a cumulative atropine dose of 100-mg within 6-h following admission or an infusion of 30 mg/h for at least 3-h. Demographic data, treatment and outcomes were recorded. Factors associated with atropine refractoriness were explored using logistic regression analysis and expressed as Odds ratio (OR) with 95% Confidence Intervals (CI). Findings: Of the 181 patients admitted with OP or Carbamate poisoning, 155 patients fulfilled inclusion criteria. The mean (SD) age was 35·7 (15·8) years; admission APACHE-II score was 14·6 (7·5). Atropine refractoriness occurred in 13·6%. In these patients, target heart rate was achieved after adding adrenaline infusion at 2-4 mcg/min. Ventilation duration (11·6±6·3 vs. 8·4±6·9 days, P=0·05) and ICU stay (12.3±5·8 vs. 8·9±5·8 days, P=0·01) were longer in atropine refractory patients when compared with non-refractory patients. On multivariate logistic regression analysis, shorter time to presentation to hospital (p=0·04) was associated with atropine refractoriness. Overall mortality was 9% and similar in refractory and non-refractory patients (P=0·41). Interpretation: Atropine refractoriness is not uncommon in OP and Carbamate poisoning and is associated with longer ventilation duration and ICU stay. Adrenaline infusion improves hemodynamics in these patients. Funding Statement: None. Declaration of Interests: There is no conflict of interest or any financial disclosures for all the authors listed in the submission. Ethics Approval Statement: The study was approved by the institutional review board (IRB) and ethics committees of the institution (IRB Min. No. 10100, dated 10.06.2016).

Intentional Carbofuran poisoning in 7 dogs

BackgroundCarbofuran is a widely used broad-spectrum pesticide that, despite strict regulation and being banned for more than a decade, is still encountered in cases of intentional poisoning in dogs and wildlife. The objective of the study was to provide a complete and detailed description of the pathological, histological and toxicological findings of 7 cases of intentional carbofuran poisoning in dogs.ResultsIn this retrospective study, 7 cases of carbofuran intoxication recorded from July 2015 to June 2017 were analyzed. Following complete history recording, all cases were examined by complete necropsy and histopathology. Carbofuran intoxication was confirmed in all cases by gas chromatography. The postmortem examination revealed extensive hemorrhaging and congestion located mainly within the respiratory, nervous and cardiovascular systems, accompanied by degeneration and necrosis within the lungs, heart, and kidneys.ConclusionsAlthough carbamates have been banned in the European Union, carbamate poisoning is still frequently encountered, especially in wild animals. This paper will contribute to a better understanding of the occurrence and pathogenesis of acute carbofuran exposure in dogs and contribute some peculiar pathological features of this type of poisoning to the current literature.