Low dose versus high dose anti-snake venom therapy in the treatment of haematotoxic snake bite in South India

Joseph, Imanto M; Kuriakose, Cijoy K; Dev, Anand; Philip, George A

doi:10.1177/0049475517712804

Cited by 8 publications

(6 citation statements)

References 8 publications

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“…These data indirectly speak to the multitude of antivenom administration practices existing in the region. [17][18][19][20][21] Some physicians advocate low-dose antivenom combined with blood products, whereas some advocate various standard doses of antivenom. 17,18,22 Even though guidelines mention paraspecific neutralization of antivenom, we do not have robust data on the degree of neutralization of other species, let alone a genus like Hypnale or Trimeresurus.…”

Section: Antivenom Usementioning

confidence: 99%

Retrospective review of case records of snakebite presenting to a single tertiary care centre over a 5-year period

MELIT

Abraham

RADHAKRISHNAN

et al. 2022

NMJI

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Background Snakebite is a disease of the poor, and hospitals catering to these individuals are often resource-constrained. Lack of electronic medical records in these resource-limited settings makes the capture of data even harder. Methods Before establishing a snakebite registry in the region, we did a retrospective case record review of all snakebite victims (n=3229) over 5 years who presented to a single tertiary care centre, catering to one of the largest number of snakebite victims in the country. Results Of the 451 cases, 262 (58.1%) presented to the emergency department within 2 hours of the bite. In 170 instances, the snake was brought along and the species of the snake was recorded. Russell’s viper was the most common (130; 76.5%). Blood products were used in 237 (52.5%) patients. Acute kidney injury occurred in 165 (36.6%) patients, of whom 37 (8.2%) required dialysis. The mean (SD) duration of hospital admission was 10.5 (7.4) days. There was a significant correlation between number of snakebites with rainfall and humidity. One hundred and seven cases (3.3%) of snakebite resulted in mortality. A majority of mortality records were not available (88%; 94/107), rendering us incapable of doing reliable mortality data correlations or interpretation. Conclusion Viperidae bites predominate in the region, with renal injury being the most common cause for morbidity. Region-specific, prospective snakebite mapping could be a cost-effective strategy that might help in vulnerability analysis of the region. A multi-centric region-specific snakebite registry encompassing not just the clinico-epidemiological characteristics of snakebite victims, but also the demographic data, the pre-hospital care and local remedial practices, geospatial distribution, anti-snake venom and blood product usage, will help in developing better healthcare strategies for snakebite victims in India.

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Section: Antivenom Usementioning

confidence: 99%

Retrospective review of case records of snakebite presenting to a single tertiary care centre over a 5-year period

MELIT

Abraham

RADHAKRISHNAN

et al. 2022

NMJI

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“…The WBCT20 has been used as the sole assessment method of VICC in numerous clinical studies, including non-randomized controlled clinical trials [ 58 ], randomized comparative trials [ 59 , 60 , 61 , 62 , 63 , 64 ], non-randomized comparative trials [ 29 , 65 ], observational studies [ 27 , 31 , 32 , 35 , 37 , 41 , 43 , 47 , 50 , 52 , 53 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 ] and case series [ 77 , 78 , 79 , 80 ].…”

Section: Types Of Bedside Coagulation Tests For Viccmentioning

confidence: 99%

Bedside Coagulation Tests in Diagnosing Venom-Induced Consumption Coagulopathy in Snakebite

Wedasingha

Silva

2020

Toxins

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Venom-induced consumption coagulopathy is the most important systemic effect of snake envenoming. Coagulation tests are helpful to accurately and promptly diagnose venom-induced consumption coagulopathy and administer antivenom, which is the only specific treatment available. However, bedside clotting tests play a major role in diagnosing coagulopathy in low-income settings, where the majority of snakebites occur. We conducted a literature search in MEDLINE® from 1946 to 30 November 2019, looking for research articles describing clinical studies on bedside coagulation tests in snakebite patients. Out of 442 articles identified, 147 articles describing bedside clotting assays were included in the review. Three main bedside clotting tests were identified, namely the Lee–White clotting test, 20-min whole blood clotting time and venous clotting time. Although the original Lee–White clotting test has never been validated for snake envenoming, a recently validated version has been used in some South American countries. The 20-min whole blood clotting time test is the most commonly used test in a wide range of settings and for taxonomically diverse snake species. Venous clotting time is almost exclusively used in Thailand. Many validation studies have methodological limitations, including small sample size, lack of case-authentication, the inclusion of a heterogeneous mix of snakebites and inappropriate uses of gold standard tests. The observation times for bedside clotting tests were arbitrary, without proper scientific justification. Future research needs to focus on improving the existing 20-min whole blood clotting test, and also on looking for alternative bedside coagulation tests which are cheap, reliable and quicker.

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“…those occurring in 5% or fewer patients). In the dosefinding trials displayed in S1 Table, six studies demonstrate a trend suggestive of a dose-toxicity relationship [26,27,[40][41][42][43], two studies show the opposite relationship [44,45] and the remaining eight studies do not report toxicity as an outcome. An earlier study by Reid with large numbers of patients was suggestive of a dose-toxicity relationship [46].…”

Section: The Importance Of Choosing the Correct Efficacy And Toxicitymentioning

confidence: 99%

A Bayesian phase 2 model based adaptive design to optimise antivenom dosing: Application to a dose-finding trial for a novel Russell’s viper antivenom in Myanmar

et al. 2020

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For most antivenoms there is little information from clinical studies to infer the relationship between dose and efficacy or dose and toxicity. Antivenom dose-finding studies usually recruit too few patients (e.g. fewer than 20) relative to clinically significant event rates (e.g. 5%). Model based adaptive dose-finding studies make efficient use of accrued patient data by using information across dosing levels, and converge rapidly to the contextually defined ‘optimal dose’. Adequate sample sizes for adaptive dose-finding trials can be determined by simulation. We propose a model based, Bayesian phase 2 type, adaptive clinical trial design for the characterisation of optimal initial antivenom doses in contexts where both efficacy and toxicity are measured as binary endpoints. This design is illustrated in the context of dose-finding for Daboia siamensis (Eastern Russell’s viper) envenoming in Myanmar. The design formalises the optimal initial dose of antivenom as the dose closest to that giving a pre-specified desired efficacy, but resulting in less than a pre-specified maximum toxicity. For Daboia siamensis envenoming, efficacy is defined as the restoration of blood coagulability within six hours, and toxicity is defined as anaphylaxis. Comprehensive simulation studies compared the expected behaviour of the model based design to a simpler rule based design (a modified ‘3+3’ design). The model based design can identify an optimal dose after fewer patients relative to the rule based design. Open source code for the simulations is made available in order to determine adequate sample sizes for future adaptive snakebite trials. Antivenom dose-finding trials would benefit from using standard model based adaptive designs. Dose-finding trials where rare events (e.g. 5% occurrence) are of clinical importance necessitate larger sample sizes than current practice. We will apply the model based design to determine a safe and efficacious dose for a novel lyophilised antivenom to treat Daboia siamensis envenoming in Myanmar.

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Low dose versus high dose anti-snake venom therapy in the treatment of haematotoxic snake bite in South India

Cited by 8 publications

References 8 publications

Retrospective review of case records of snakebite presenting to a single tertiary care centre over a 5-year period

Retrospective review of case records of snakebite presenting to a single tertiary care centre over a 5-year period

Bedside Coagulation Tests in Diagnosing Venom-Induced Consumption Coagulopathy in Snakebite

A Bayesian phase 2 model based adaptive design to optimise antivenom dosing: Application to a dose-finding trial for a novel Russell’s viper antivenom in Myanmar

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