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PROGNOSTIC FACTORS IN ACUTE ALUMINIUM PHOSPHIDE POISONING: A PROSPECTIVE STUDY AT TERTIARY CARE HOSPITAL FROM NORTH INDIA
Premshanker Singh*, Richa Choudhary, Manoj Kumar, Granth Kumar and Dheeraj Kela
Aluminum phosphide (ALP), an inexpensive solid fumigant, is frequently used for grain conservation despite its alleged high toxicity. Increased utilization of ALP for agricultural and non-agricultural purposes during the last four decades has resulted in increment of ALP-attributed poisoning numbers. Moreover, due to its limitless accessibility in developing countries, ALP has been increasingly used for suicide. Moisture-exposed ALP undergoes a chemical reaction producing phosphine gas, which in turn inhibits cytochrome oxidase and impedes cellular oxygen consumption. Lethality remains elevated reaching rates of >50% and no effective antidote is available. Nevertheless, experimental and clinical studies suggested that magnesium sulfate, melatonin, N-acetylcysteine, glutathione, sodium selenite, vitamin C and E, triiodothyronine, liothyronine, vasopressin, milrinone, Laurusnobilis L., 6-aminonicotinamide, boric acid, acetyl-L-carnitine and coconut oil, may serve as antidotes by reducing the deleterious oxidative properties of ALP. Commercial formulations, which usually contain 55 to 75% active ingredient, are sold in the form of tablets. Aluminum phosphide is available without restriction in some countries. In India, for example, ALP poisoning, which was almost nonexistent a three decade ago, has now reached epidemic proportions, and many reports of high mortality (> 50%) have recently been published . Pellets of solid aluminum phosphide react rapidly with water Aluminium phosphide (AlP) is a toxic agent associated with a high mortality rate following acute exposure from various routes. The aim of this study was to determine the clinical and laboratory findings useful for predicting the medical outcome of ALP-poisoned patients using established scoring systems. This is a prospective study of ALP-poisoned patients from 2008 to 2017 at UP University of Medical Sciences from North India. All patients that presented with a confirmed diagnosis of acute ALP poisoning in the study interval were included in the study. Clinical and laboratory data, using Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA) and Simplified Acute Physiology Score II (SAPS II) scoring systems, were compared for their predictive value in determining differences between survived and non-survived patients. Univariate analysis (t-test), multiple logistic regression analysis, receiver operating characteristic (ROC), curve analysis and the Pearson correlation test were performed using STATA/SE 13.0 and the Nomolog Software. A total of 38 ALP-poisoned patients with confirmed acute ALP poisoning were included for evaluation. Of these, 18 were non-survived. Multiple logistic regression analysis was performed using parameters and values derived from patient clinical and laboratory data, and revealed that four factors were significant for predicting mortality: Glasgow coma score (GCS); systolic blood pressure (SBP); urinary output (UOP); and serum HCO3. A four-variable, risk-prediction nomogram was developed for identifying high-risk patients and predicting the risk of mortality. Study results showed that SBP of 24.5, APACHE II score >8.5 and SOFA score >7.5 were predictive of non-survival patients. The results of our study showed that SBP, GCS, UOP and serum HCO3 levels are the best prognostic factors for predicting mortality in ALP-poisoned patients.[Full Text Article] [Download Certificate]