Oxime and atropine failure to prevent intermediate syndrome development in acute organophosphate poisoning

Slavica Vučinić; Biljana Antonijević; Nela Ilić; Tihomir Ilić

doi:10.2298/1637

Slavica Vučinić National Poison Control Centre, Military Medical Academy, Belgrade, Serbia; Faculty of Medicine of the Military Medical Academy University of Defence, Belgrade, Serbia
Biljana Antonijević Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia
Nela Ilić Clinic of Physical Medicine and Rehabilitation, Clinical Center of Serbia, Belgrade, Serbia
Tihomir Ilić Outpatient Neurology Service and Department of Clinical Neurophysiology, Military Medical Academy, Belgrade, Serbia; Faculty of Medicine of the Military Medical Academy University of Defence, Belgrade, Serbia

DOI: https://doi.org/10.2298/1637

Ključne reči: poisoning||, ||trovanje, phosphoric acid esters||, ||estri fosforne kiseline, neurotoxicyty syndromes||, ||neurotoksičnost, sindromi, atropine||, ||atropin, oksimes||, ||oksimi, respiration, artificial||, ||disanje, veštačko, treatment outcome||, ||lečenje, ishod,

Sažetak

Uvod.

Intermedijerni sindrom (IMS) opisan je pre nekoliko decenija, međutim i dalje postoje kontroverze u vezi sa njegovom etiologijom, faktorima rizika, dijagnostičkim parametrima i potrebnom terapijom. S obzirom na to da se akutna trovanja leče u medicinskim ustanovama različitog tipa, ova teљka komplikacija akutnih trovanja organofosfornim insekticidima (OFI) često se ne prepoznaje. Cilj rada bio je da se prikaћe slučaj akutnog trovanja organofosfornim insekticidom koji će dati dodatne podatke o upotrebi oksima i atropina. Prikaz bolesnika. Nakon kupirane holinergičke krize kod bolesnika, 72 h od namerne ingestije malationa, doљlo je do razvoja kliničke slike IMS. Znaci IMS su uključivali slabost miљića gornjih ekstremiteta i miљića inervisanih motornim kranijalnim nervima, љto je bilo praćeno slaboљću respiratorne muskulature i teљkom respiratornom insuficijencijom. Malation i njegov aktivni metabolit potvrđeni su analitičkom procedurom (tečna hromatografija-masena spektrometrija). Kontinuiranom infuzijom pralidoksim metilsulfata do osmog dana (ukupno 38,4 g) i atropina do desetog dana (ukupna doza 922 mg), nije sprečen razvoj IMS, te je mehanička ventilacija, koja je prekinuta nakon 27 h, morala biti nastavljena do desetog dana. Zaključak. Kontinuiranom infuzijom pralidoksim-metilsulfata i atropina nije sprečen razvoj IMS, najverovatnije zbog odloћenog početka lečenja i nedovoljne doze primenjenog oksima, ali i hemijske strukture i lipofilnosti ingestiranog OFI. Istaknut je značaj produћene o pservacije u jedinici intenzivne nege i respiratorne podrљke u lečenju intermedijernog sindroma.

Reference

Senanayake N, Karalliedde L. Neurotoxic effects of orga-nophosphorus insecticides. An intermediate syndrome. N Engl J Med 1987; 316(13): 761−32.

Wadia RS, Chitra S, Amin RB, Kiwalkar RS, Sardesai HV. Electrophysiological studies in acute organophosphate poi-soning. J Neurol Neurosurg Psychiatry 1987; 50(11): 1442−8.

Aaron CK, Smilkstein MJ. Organophosphate poisoning: In-termediate syndrome or inadequate therapy. Vet Hum Toxicol 1988; 30: 370.

De Bleecker JL. The intermediate syndrome in organo-phosphate poisoning: an overview of experimental and clinical observations. J Toxicol Clin Toxicol 1995; 33(6): 683−6.

Sudakin DL, Mullins ME, Horowitz BZ, Abshier V, Letzig L. Intermediate syndrome after malathion ingestion despite continuous infusion of pralidoxime. J Toxicol Clin Toxi-col 2000; 38(1): 47−50.

Vale JA, Kulig K. Position paper: gastric lavage. J Toxicol Clin Toxicol 2004; 42(7): 933−43.

Eddleston M, Juszczak E, Buckley NA, Senarathna L, Mo-hamed F, Dissanayake W, et al. Multiple-dose activated charcoal in acute self-poisoning: a randomised controlled trial. Lancet 2008; 371(9612): 579−87.

Benson BJ, Tolo D, McIntire M. Is the intermediate syn-drome in organophosphate poisoning the result of insuffi-cient oxime therapy? J Toxicol Clin Toxicol 1992; 30: 347−9.

Pawar KS, Bhoite RR, Pillay CP, Chavan SC, Malshikare DS, Garad SG. Continuous pralidoxime infusion versus re-peated bolus injection to treat organophosphorus pesticide poisoning: a randomised controlled trial. Lancet 2006; 368(9553): 2136−41.

De Wilde V, Vogelaers D, Colardyn F, Vanderstraeten G, Van den Neucker K, De Bleecker J, et al. Postsynaptic neu-romuscular dysfunction in organophosphate induced in-termediate syndrome. Klin Wochenschr 1991; 69(4): 177−83.

Dandapani M, Zachariah A, Kavitha MR, Jeyaseelan L, Oommen A. Oxidative damage in intermediate syndrome of acute organophosphorous poisoning. Indian J Med Res 2003; 117: 253−9.

John M, Oommen A, Zachariah A. Muscle injury in orga-nophosphorous poisoning and its role in the development of intermediate syndrome. Neurotoxicology 2003; 24(1): 43−53.

Sedgwick EM, Senanayake N. Pathophysiology of the in-termediate syndrome of organophosphorus poisoning. J Neurol Neurosurg Psychiatry 1997; 62(2): 201−2.

Karalliedde L, Baker D, Marrs TC. Organophosphate-induced intermediate syndrome: aetiology and relation-ships with myopathy. Toxicol Rev 2006; 25(1): 1−14.

Jayawardane P, Dowson A, Senanayake N, Weerasinghe V. Serial neurophysiological studies in 70 patients with orga-nophosphate poisoning: early prediction of intermediate syndrome. Clin Toxicol 2006; 44: 729.

Eyer P, Worek F, Thiermann H, Eddleston M. Paradox find-ings may challenge orthodox reasoning in acute organo-phosphate poisoning. Chem Biol Interact 2010; 187(1−3): 270−8.

Buckley NA, Eddleston M, Li Y, Bevan M, Robertson J. Ox-imes for acute organophosphate pesticide poisoning. Co-chrane Database Syst Rev 2011; (2): CD005085.

Neuspeh sprečavanja razvoja intermedijernog sindroma kod akutnog trovanja organofosfornim insekticidima primenom oksima i atropina

Sažetak

Reference