Effectiveness of clotting factor replacement therapy after antivenom treatment on coagulopathic envenomation following green pit viper bites: a retrospective observational study

Abstract

Background Green pit vipers (GPVs), namely Trimeresurus albolabris and Trimeresurus stejnegeri accounts for most snakebites in Southern China. Green pit viper venom contains thrombin-like enzymes, resulting in defibrination syndrome. Using of clotting factor replacement after antivenom administration is controversial. The objective of this study was to investigate the effects of clotting factor replacement in coagulopathic patients with T. albolabris and T. stejnegeri bites after antivenom administration. Methods We retrospectively reviewed 123 patients who were bitten by T. albolabris and T. stejnegeri and were admitted to the Emergency Department of a hospital in Guangzhou, Southern China, from 2013 to 2019. Recovery of prothrombin time (PT) and fibrinogen level were compared among (1) fresh-frozen plasma (FFP) group; (2) cryoprecipitate (cryo) group; (3) FFP and cryo group; and (4) control group after antivenom administration. Results The incidence of coagulopathy was 31%. Persistent and late coagulopathy were the most common patterns among four groups. The median reduction in PT was 20.1 ± 31.2 s for FFP and cryo group. The median increase in fibrinogen level was very small: 0.05 ± 0.20 g/L for FFP group, 0.09 ± 0.37 g/L for cryo group and 0.07 ± 0.31 g/L for FFP and cryo group, respectively. The percentage of unimproved PT was markedly higher in the FFP and cryo group than the control group (P = 0.01 by log-rank test, P = 0.02 by Gehan-Breslow-Wilcoxon test). The percentage of unimproved fibrinogen level tended to be worse in the FFP and cryo group than the control group, but the different was marginal (P = 0.05 by Gehan-Breslow-Wilcoxon test, P = 0.07 by log-rank test). A total of 7.8% (7/90) of the patients in the clotting factor replacement groups developed anaphylaxis and heart failure. Conclusion There is no improvement in coagulopathy profile in patients with T. albolabris and T. stejnegeri bites who received clotting factor replacement after antivenom administration. But the results from GPVs may not be generalized to other species of venomous snakes.

Associated Clinical Factors for Coagulation Dysfunction due to Trimeresurus stejnegeri: A Retrospective Observational Study

“…Antivenom can just work on the unbound free venom in circulation, while the entered venom has already resulted in a cascade of coagulation factor consumption. Many physicians sought mounts of methods to replenish the lack of antivenom effectiveness on coagulopathy status post snakebites, but the effectiveness remains controversial and is still investigation [ 2 , 28 – 30 ].…”

“…Snakebite remains a very common medical emergency in China [ 1 ]. Trimeresurus stejnegeri (T.s), also known locally as the bamboo snake, accounts for most human envenomation cases in south China, such as Guang-Dong, Tai-Wan, Guang-Xi, and San-Ya [ 2 – 6 ]. The ratio of T.s bitten ranks high among the dozes of venomous snake bites in China.…”

The use of antivenom serum, fresh frozen plasma, and platelet concentrate for management strategy of snakebite related coagulopathy: a case series

“…Proteases from the venom can impair the physiological coagulation process. 6,7 Therefore, it still is necessary to provide additional therapy aimed at improving coagulation function to prevent bleeding and further coagulation disorders.…”

“…8 The addition of FFP (if not available can also use TC or even whole-blood) transfusion may be considered in patients receiving suboptimal SABU dose or even suspected of having a severe hemotoxic reaction. 6 The use of additional FFP, based on a recent study in Australia, can be used to achieve rapid control of coagulation function (achieving INR < 2) when given within 4 h of initial administration of SABU. 9 However, meta-analyses examining FFP administration for VICC (venom-induced consumptive coagulopathy) emphasized that maximum effectiveness of FFP administration can be achieved when administered 6 h post-bite (in patients with active bleeding).…”