Predicting Outcome in Organophosphorus Poisoning Using RBC Cholinesterase and Serum Cholinesterase Values: A Hospital-based Longitudinal Study

Abstract

Background Organophosphorus (OP) poisoning is a leading cause of mortality due to self-harm in Asian countries, including India. Red blood cell cholinesterase (RBC-ChE) and serum cholinesterase (serum-ChE) levels are used for predicting outcomes. There is a paucity of literature studying the RBC-ChE levels in OP poisoning and comparing it with the serum-ChE levels.

Methods This is a longitudinal study assessing the outcome in OP poisoning patients using the RBC-ChE and serum-ChE levels. Both enzyme levels are compared and correlated for adult patients presenting within 24 hours of consumption of the OP compound. Sensitivity and specificity are measured.

Results Of the 99 OP poisoning patients included, 20 patients did not survive, and 23 patients required ventilatory support. At admission, RBC-ChE (median, interquartile range [IQR]) was significantly different between survivors (45.2 [30.5–60] U/g Hb) and nonsurvivors (6.3 [4.2–13.4] U/g Hb), while serum-ChE (median, IQR) was not statistically different (p = 0.061) between survivors (350 [247–670]) and nonsurvivors (290 [182–415.8]). Similarly, RBC-ChE was significantly different between patients requiring a ventilator and those not requiring a ventilator (6.8 vs. 44.2 U/g Hb), whereas the serum-ChE values measured on admission were not significantly different for patients requiring a ventilator versus those not requiring a ventilator (290 vs. 348 U/L; p = 0.119). At the cutoff of 20 U/g Hb, RBC-ChE had 90.5% sensitivity and 91% specificity in predicting mortality. Kaplan–Meier survival showed the probability of survival decreased to nearly 50% if the time to reach the hospital was ≥4 hours.

Conclusion RBC-ChE was superior in predicting outcomes in OP poisoning patients compared with serum-ChE measured on the day of admission.

Keywords

cholinesterase - Kaplan–Meier - organophosphorus - pesticides - poisoning - RBC cholinesterase

Compliance with Ethical Standards

The study was conducted in accordance with the ethical standards as laid down in the Declaration of Helsinki and its later amendments or comparable ethical standards.

Ethical Approval

The study was approved by the Institutional Ethics Committee of S.C.B. Medical College and Hospital, Cuttack, vide IEC/IRB no. 402/14.10.2020.

Informed Consent

Informed consent was obtained from each participant in written form in the local Odia language. In a situation where the participant could not provide consent, informed consent was obtained from their first-degree relative/legal guardian.

Author Contributions

S.K. contributed to the conception, data collection, and drafting of the manuscript. N.R.M. contributed to the study design and review of literature. B.P. contributed to review of the literature and revising the manuscript. R.R. contributed to biochemical measurements and review of the manuscript. A.C. contributed to statistical analysis, interpretation of data, and preparation of tables and figures. S.P. contributed to review of the manuscript. P.K.R. was responsible for reference management. B.D. provided assistance during patient interaction and contributed to review of the manuscript. B.R.P. contributed to review of the manuscript and the references. P.K.T. contributed to conception, interpretation of data, and review of the manuscript.

Publikationsverlauf

Eingereicht: 25. Mai 2023

Angenommen: 27. Juli 2023

Artikel online veröffentlicht:
28. September 2023

• References

• 1 Karunarathne A, Gunnell D, Konradsen F, Eddleston M. How many premature deaths from pesticide suicide have occurred since the agricultural Green Revolution?. Clin Toxicol (Phila) 2020; 58 (04) 227-232
• 2 World Health Organization. Guidelines for Establishing a Poison Centre. Geneva: WHO; 2020
• 3 Gargi J, Tejpal H, Chanana A, Rai G, Chaudhary R. A retrospective autopsy study of poisoning in the northern region of Punjab. J Punjab Acad Forensic Med Toxicol. 2008; 8 (02) 17-19
• 4 Harish D, Sharma B, Chavali K, Sharma A. Poisoning mortality in Chandigarh: an overview. J Indian Forensic Med 2006; 28 (03) 110-113
• 5 Dawson AH, Eddleston M, Senarathna L. et al. Acute human lethal toxicity of agricultural pesticides: a prospective cohort study. PLoS Med 2010; 7 (10) e1000357
• 6 Lotti M. Cholinesterase inhibition: complexities in interpretation. Clin Chem 1995; 41 (12, Pt 2): 1814-1818
• 7 Namba T. Cholinesterase inhibition by organophosphorus compounds and its clinical effects. Bull World Health Organ 1971; 44 (1–2–3): 289-307
• 8 Roberts DM, Aaron CK. Management of acute organophosphorus pesticide poisoning. BMJ 2007; 334 (7594) 629-634
• 9 Senanayake N, de Silva HJ, Karalliedde L. A scale to assess severity in organophosphorus intoxication: POP scale. Hum Exp Toxicol 1993; 12 (04) 297-299
• 10 Lotti M. Clinical toxicology of anticholinesterase agents in humans. In: Krieger R. ed. Hayes' Handbook of Pesticide Toxicology. 3rd ed.. New York, NY: Academic Press; 2010: 1543-1589
• 11 Robles A, Michael M, McCallum R. Pseudocholinesterase deficiency: what the Proceduralist needs to know. Am J Med Sci 2019; 357 (03) 263-267
• 12 Herkert NM, Aurbek N, Eyer P, Thiermann H, Worek F. Comparative study of oxime-induced reactivation of erythrocyte and muscle AChE from different animal species following inhibition by sarin or paraoxon. Toxicol Lett 2010; 194 (03) 94-101
• 13 Thiermann H, Zilker T, Eyer F, Felgenhauer N, Eyer P, Worek F. Monitoring of neuromuscular transmission in organophosphate pesticide-poisoned patients. Toxicol Lett 2009; 191 (2–3): 297-304
• 14 Thiermann H, Worek F, Szinicz L. et al. On the atropine demand in organophosphate poisoned patients. J Toxicol Clin Toxicol 2003; 41: 457
• 15 Eddleston M, Dawson A, Karalliedde L. et al. Early management after self-poisoning with an organophosphorus or carbamate pesticide: a treatment protocol for junior doctors. Crit Care 2004; 8 (06) R391-R397
• 16 Sanz P, Rodriguez-Vicente MC, Diaz D, Repetto J, Repetto M. Red blood cell and total blood acetylcholinesterase and plasma pseudocholinesterase in humans: observed variances. J Toxicol Clin Toxicol 1991; 29 (01) 81-90
• 17 Nouira S, Abroug F, Elatrous S, Boujdaria R, Bouchoucha S. Prognostic value of serum cholinesterase in organophosphate poisoning. Chest 1994; 106 (06) 1811-1814
• 18 Patel P, Patel VP, Patel H, Rathod GB. Study of prognostic value of serum and RBC acetyle cholinesterase level in organophosphorus poisoning and its correlation with the outcome. Inter Arch Integrated Med. 2016; 3 (03) 147-157
• 19 Rehiman S, Lohani SP, Bhattarai MC. Correlation of serum cholinesterase level, clinical score at presentation and severity of organophosphorous poisoning. JNMA J Nepal Med Assoc 2008; 47 (170) 47-52
• 20 Yamashita M, Yamashita M, Tanaka J, Ando Y. Human mortality in organophosphate poisonings. Vet Hum Toxicol 1997; 39 (02) 84-85
• 21 Sungur M, Güven M. Intensive care management of organophosphate insecticide poisoning. Crit Care 2001; 5 (04) 211-215
• 22 Patil G, Nimbal NV, Joshi AV, Dambal A, Madhavaranga MP, Halki S. Role of serum cholinesterase in acute organophosphorus poisoning: A hospital based cross sectional study. J Evol Med Dent Sci 2015; 4 (30) 5102-5109
• 23 Hussain AM, Sultan ST. Organophosphorus insecticide poisoning: management in surgical intensive care unit. J Coll Physicians Surg Pak 2005; 15 (02) 100-102
• 24 Aygun D, Doganay Z, Altintop L. et al. Serum acetylcholinesterase and prognosis of acute organophosphate poisoning. J Toxicol Clin Toxicol 2002; 40 (07) 903-910
• 25 Chen HY, Wang WW, Chaou CH, Lin CC. Prognostic value of serial serum cholinesterase activities in organophosphate poisoned patients. Am J Emerg Med 2009; 27 (09) 1034-1039
• 26 Yun HW, Lee DH, Lee JH, Cheon YJ, Choi YH. Serial serum cholinesterase activities as a prognostic factor in organophosphate poisoned patients. Hong Kong Med J 2012; 19 (02) 92-97