Clinical Analysis Of 1018 Acute Poisoning Patients In ICU

Background: Acute poisoning is one of the major diseases in emergency sphere. People's living and working pressure increases with the rapid development of social economy, and the incidence of acute poisoning is increasing year by year because of more opportunities of contacting with chemicals. Acute poisoning often results in MODS. Most severe patients who die are closely related with MODS. Acute poisoning has become an important part of severe patients in ICU of many hospitals presently. It is significant for guiding the treatment to study the epidemiologic feature and the risk factors of prognosis of acute poisoning, but there are few reports at present. This study investigated 1018 cases of acute poisoning in ICU of the second hospital of Jilin University, and we studied the epidemiologic feature, the cases with MODS and the prognostic risk factors of acute poisoning. The aims were to provide the scientific basis for therapeutic strategies of severe acute poisoning.Purpose: To study the epidemiologic feature and the MODS's characteristics of intoxication, explore the prognostic risk factors and provide the scientific basis for therapeutic strategies of acute poisoning by analyzing the clinical data of 1018 acute poisoning patients in ICU.Method: The clinical data of 1018 acute poisoning patients was collected during the time from January 1, 2000 to December 30, 2009 in ICU of the second clinical hospital of Jilin university, and the blanks of acute poisoning cases were filled. The epidemiologic feature and the conditions of injured organ were statistically analyzed by proper statistical methods. Some prognostic risk factors of 356 cases with complete clinical data were studied by single-factor analysis and Logistic multiple regression, such as gender, age, intoxicated cause, type of poison, length of stay, cardio-pulmonary resuscitation, mechanical ventilation, APACHEⅡscore and so on.Results:1,Epidemiologic feature of 1018 acute poisoning cases The number of female was more than male among 1018 acute poisoning cases (1.43: 1). High incidence groups were at the age of 20～29(30.35%) and 30～39(24.85%). The top occupation was peasants(61.89%), and the rest occupations from high to low were the unemployed people(18.57%), worker(11.59%),student(4.91) and cadre(0.2%). The first cause of intoxication was suicide (90.57). The top 10 poison categories were organophosphorus pesticides, rodenticides, hypnotics, paraquat, antipsychotics, carbamates, antipyretic analgesic, alcohol, herbicides and poisonous mushroom. The intoxication from digestive tract was the most common in all intoxicated pathway (96.17).The average length of stay (LOS) was 3.90 days, and the case fatality rate was 10.90%.2, Clinical analysis of 455 acute poisoning cases with MODSThe incidence rate of MODS among 1018 acute poisoning patients reached 44.70%. The top five causes of MODS were organophosphate poisoning (28.79%), paraquat poisoning (13.85%), antipsychotic poisoning (8.79%), carbamate poisoning (8.57%) and hypnotics poisoning (8.35%). The top two organs which had highest incidence rate of organ dysfunction were brain (79.78%) and lung (71.21%),and the rest organs were circulation system (58.02%), liver (50.33%), kidney (19.34%), coagulation system (13.85%) and gastrointestinal tract (7.25%). The case fatality rate of MODS with 2, 3, 4, 5, 6 or more organ dysfunction was 4.68%, 15.38%, 46.38%, 71.79% and 100%, and the total case fatality rate of 455 cases with MODS was 24.40%.3, prognostic risk factors of acute poisoning356 cases with complete data were divided into survival group and death group. Univariate analysis showed that the length of stay, APACHEⅡscore, time between poisoning and hospitalization in ICU, cardio-pulmonary resuscitation, mechanical ventilation, poison category demonstrated statistical significance (P<0.05 or <0.01) between death group and survival group. Multivariate Logistic regression analysis revealed that the length of stay, APACHEⅡscore, cardio-pulmonary resuscitation, mechanical ventilation, poison category positively correlated with death of acute poisoning(P<0.05).Discussion: Acute poisoning is common one of serious illness in emergency department and ICU. This study about 1018 acute poisoning cases showed that female were more than male, and this result was consistent with most of the literature reports [41, 42]. The youth and postadolescence (age 20 to 40) had higher risk of acute poisoning than others. There was a significant difference in gender between the two groups that people were below 40 and above 40 years. There were more women in the group below 40 years. The age distribution was similar with the reports of American Association of Poison Control Center and most of Chinese research. The first cause of intoxication was suicide (90.57). Damage and unnatural deaths caused by spontaneous behavior of young patients below 40 years damaged the family and society. The reason may be related to the following factors: living and working pressure, more opportunities to contact poison and lack of proper psychological treatment. Therefore family and society should pay more attention to the working environment,living status and mental health of these people to reduce the occurrence of acute poisoning. Some patients with mental disorder or depression were prone to poison secondarily or repeatedly,and doctors should give them normal psychological treatment and pay more attention to their health care. These occupational distributions of 1018 cases were peasants, unemployed people, workers, students. It was similar with Chenjiao's [50] research that 61.89% of the patients were peasants. The result may be related to the source of sample. There's a big scale of agricultural production in Jilin province. Peasants here have more opportunities to contact with agricultural pesticide. Patients of pesticide poisoning who were more complex and prone to synchronize MODS were usually required to be treated in ICU. There were more than 40 poisons in these data including pesticides, pharmaceuticals, poisonous plants and animals, industrial poisons etc. The top 10 poisons were organophosphorus pesticides, rodenticides, hypnotics, paraquat, antipsychotics, carbamates, antipyretic analgesic,alcohol, other herbicides and poisonous mushroom. It was similar with Hongguangliang's [51] research that 25.54% of the patients were acute organophosphorus poisoning. But the result was dissimilar with other reports [52, 63] which top poisons were hypnotics and alcohol. The result may be related to the population differences and other factors. Most of the patients of acute alcohol poisoning and hypnotics poisoning were not very severe, so they could be mainly treated in the emergency room. There were 12.68% of the patients with two or more intoxicants poisoning in these data. Doctors should pay more attention to such patients, because their pathogenetic conditions may be more complex. It was similar with other reports that the top intoxicated pathway was digestive tract. The length of stay was related to many factors, such as poisons, doses, complications, severity, family's economic status and so on [50]. The average length of stay for the patients in this study was almost 4 days. There was no significant difference between the average length of stay of organophosphorus pesticides poisoning and paraquat poisoning, and they were both longer than the total average length of stay. The outcome of acute poisoning patients may be different because many factors affected them. Most of the patients treated in ICU were cured or improved, but the case fatality rate still reached 10.90%. Therefore doctors should pay more attention to the patients with critical condition and take positive measures to reduce mortality.MODS which is divided into primary MODS and insecondary MODS is a severe complication of acute poisoning. Poison or its metabolite acts on the cells of its target organs, and it may cause primary MODS by resulting in damage of a variety of tissues and cells. Acute poisoning patients are often in stress state. Hypoxia and shock which usually occur for acute poisoning patients can induce systemic inflammatory response syndrome (SIRS) and further cause secondary MODS [4, 5]. Our results showed that 455 cases of acute intoxication occurred MODS, which accounted for 44.70%. Such incidence rate of MODS was higher than report [34]. It may be related to the source of patients who treated in ICU and severity of pathogenetic condition. The top five causes of MODS were organophosphate poisoning (28.79%), paraquat poisoning (13.85%), antipsychotic poisoning (8.79%), carbamate poisoning (8.57%) and hypnotics poisoning (8.35%). The incidence rate of MODS of paraquat poisoning was higher than the ones of other pesticide poisoning. The top two organs with highest incidence rate of organ dysfunction were brain and lung, and the rest organs were circulation system, liver, kidney and others. This result was similar with most reports [34, 35]. Therefore doctors should pay more attention to protect brain and monitor respiratory function. Patients should be promptly given oxygen therapy and respiratory therapy when it's necessary. More damages of other organs caused by lack of oxygen should be refrained. The case fatality rate of acute poisoning patients heightened with the number of dysfunctional organs increasing. This study has confirmed the rule that it becomes more critical when there are more organs involved. The case fatality rate of 455 cases with MODS was 24.40%, which was lower than literature reported [34]. It may be related to some reasons below. Most patients in this study were youth and postadolescent without underlying disease, and they had good organ function. Patients treated in ICU could be monitored and remedied intensively. There was a high risk that MODS happened to the acute poisoning patients. Doctors should broaden their thinking in clinical work. When the causes of MODS are not clear we should think if it may be acute poisoning. Organ function should be monitored because MODS may happen to acute poisoning patients. Doctors should pay attention to protect organs as well as treat primary disease. Although the level of treatment in ICU increases, the case fatality rate of acute poisoning patients with MODS is still high, especially for paraquat poisoning patients. There are not effective treatments for such currently. So it is urgent that we find treatment plan to improve the success rate.The prognosis of acute poisoning is related to many factors, such as poisons, doses, complications, severity, length of stay and so on. It is very important to evaluate severity and mortality risk, and doctors could distribute medical resources reasonably and reduce medical disputes. Qiu Qiaomeng's study showed that the prognosis of acute poisoning was related to suicide, complications, hemodialysis, length of stay, costs of hospitalization, compliance and other factors [60]. Shen Min'S research revealed that benzodiazepine drug poisoning and prolonging length of stay were favorable factors, and the negative factors contained male, age and frequency of rescue [61]. Prognostic factors of 356 cases with complete data were studied in this research. Univariate analysis showed that the length of stay, APACHEⅡscore, time between poisoning and hospitalization in ICU, cardio-pulmonary resuscitation, mechanical ventilation, and poison category demonstrated statistical significance between death group and survival group. Multivariate Logistic regression analysis revealed that the length of stay, APACHEⅡscore, cardio-pulmonary resuscitation, mechanical ventilation, poison category positively correlated with death of acute poisoning. Regression model whose accuracy was 86.52% was established, and it predicted outcomes of acute poisoning well.It was similar with reports that prolonging length of stay was a positive factor of outcome in this study. Some patients with extremely severe illness died in short time after housing facility, which made the length of stay short. Other patients treated in ICU were improved by intensive therapy,and such patients'length of stay was longer than sever patients'. Disease of sever poisoning patients often progresses quickly. Respiratory failure and cardiac arrest as critical conditions could increase the acute poisoning patients'risk of death. This study showed that the case-fatality rates of poisoning patients with different poisons were significant differences. The outcome was related to the different poisons, which has been tested by Chi-square test and Logistic regression analysis in this study. The case-fatality rate of paraquat poisoning is highest. The prognosis was unrelated to the length between poisoning and visit, which was inconsistent with reports. It may be related to poisons, doses, pharmacological properties and so on. The prognostic evaluation system of APACHEⅡscore has been widely used to evaluate critical diseases, and literatures reported that it could predict the prognosis of acute poisoning patients. This study also demonstrated the rule. The fatality rate was higher than 80% if APACHEⅡscore of acute poisoning patients was more than 20 scores [64, 66]. Therefore acute poisoning patients with high APACHEⅡscore should be treated early in ICU. Doctors should actively communicate with patients'family, which could distribute medical resources reasonably and reduce medical disputes. We hope to offer some message about medical evaluation of severity and prognosis through analyzing the prognostic factors of acute poisoning patients.Conclusion:1018 acute poisoning patients have their own clinical characteristics in ICU of the second hospital of Jilin University. Severe poisoning patients have high risk of incidence rate of MODS. The case fatality rate is closely related to the number of dysfunctional organ. Severe poisoning patients should be treated in ICU early. Hospital stay, APACHEⅡscore, cardio-pulmonary resuscitation, mechanical ventilation and poison category were independent risk factor of prognosis. APACHEⅡscore system and Logistic regression analysis can be used for evaluating the severity and prognosis of acute poisoning patients.