Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantari Nagar, Puducherry, India.
Department of Forensic Medicine and Toxicology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantari Nagar, Puducherry, India.
QJM. 2018 Nov 1;111(11):799-806. doi: 10.1093/qjmed/hcy175.
Viper envenomation contributes to nearly 50% of snake-bite deaths in India, chiefly due to circulatory shock. The mechanisms leading to circulatory shock include bleeding, capillary leak syndrome (CLS) and myocardial depression. Pituitary-adrenal axis involvement in circulatory shock, though described, has not been fully elucidated.
To identify predictors of circulatory shock and mortality in viper envenomation and explore the role of pituitary-adrenal axis in circulatory shock.
Prospective hospital-based observational study.
Once a syndromic diagnosis of viper envenomation was made, relevant clinical and laboratory data were collected. Serum cortisol was estimated in those with circulatory shock. Post-mortem examination of pituitary, kidneys and adrenals was performed. Adjusted odds-ratios were calculated for respective risk-factors for shock and mortality using multivariable logistic regression with backward elimination strategy.
Of 248 patients of viper envenomation treated at our hospital, circulatory shock was present in 19% and in-hospital mortality was 23%. CLS, circulatory shock, bleeding and requirement of > 20 vials of antivenom predicted mortality. Ischaemic and haemorrhagic necrosis of pituitary or adrenals was present in 51% of post-mortem specimens. Disseminated intravascular coagulation (DIC) and CLS were strong predictors of pituitary haemorrhage.
Predictors of mortality - bleeding, CLS and requirement of high antivenom doses are warning signs which can alert clinicians to patients who may have poor outcomes. Our study points to a definite role of pituitary-adrenal axis in circulatory shock supports the hypothesis that pituitary involvement in viper envenomation closely resembles Sheehan syndrome. The mechanism of pituitary involvement appears to be a result of increased susceptibility of the swollen gland secondary to CLS and micro thrombi deposition in DIC.
在印度，毒蛇咬伤导致近 50%的死亡，主要是由于循环性休克。导致循环性休克的机制包括出血、毛细血管渗漏综合征（CLS）和心肌抑制。尽管已经描述了垂体-肾上腺轴在循环性休克中的参与，但尚未完全阐明。
确定毒蛇咬伤中循环性休克和死亡的预测因素，并探讨垂体-肾上腺轴在循环性休克中的作用。
前瞻性医院观察性研究。
一旦做出毒蛇咬伤的综合征诊断，就收集相关的临床和实验室数据。对有循环性休克的患者进行血清皮质醇估计。对垂体、肾脏和肾上腺进行尸检。使用具有后向消除策略的多变量逻辑回归计算各自的休克和死亡率风险因素的调整优势比。
在我院治疗的 248 例毒蛇咬伤患者中，有 19%出现循环性休克，院内死亡率为 23%。CLS、循环性休克、出血和需要>20 支抗蛇毒血清预测死亡率。51%的尸检标本中存在垂体或肾上腺的缺血性和出血性坏死。弥散性血管内凝血（DIC）和 CLS 是垂体出血的强预测因素。
死亡率的预测因素——出血、CLS 和需要大剂量抗蛇毒血清——是可以提醒临床医生注意可能预后不佳的患者的警告信号。我们的研究表明，垂体-肾上腺轴在循环性休克中确实起作用，支持了垂体在毒蛇咬伤中参与的假说类似于席汉综合征。垂体参与的机制似乎是由于 CLS 和 DIC 中小血栓沉积导致肿胀腺体的易感性增加。
