الفهرس 
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Abstract
Acute cholinesterase pesticide poisoning is a common medical and toxicological emergency globally, particularly in developing nations like Egypt. Poisoning may occur through occupational exposure or accidental ingestion, but many cases are intentional, with suicidal motives. Therefore, it is crucial to recognize clinical features and other indicators that can assess the severity of poisoning and foresee the necessity for ventilatory support at the initial evaluation.
The primary causes of early mortality in acute cholinesterase pesticide poisonings are respiratory failure and ventricular arrhythmias. Respiratory failure usually arises from excessive bronchial secretions, bronchospasm, pulmonary edema, aspiration of gastric contents, paralysis of respiratory muscles, or apnea due to medullary respiratory center depression. Mechanical ventilation may be a vital treatment for these complications.
The objective of this prospective cohort study was to determine the predictive value of SOFA-Lac and QTc interval for mechanical ventilation in patients with acute poisoning from cholinesterase inhibitor pesticides.
The study involved patients of both sexes who experienced acute toxic exposure to cholinesterase inhibitor pesticides and were admitted to the Poison Control Center of Ain Shams University hospitals from December 2022 to May 2023. A total of 50 patients were categorized into two groups: those who received mechanical ventilation and those who did not.
For each patient, socio-demographic data, details of intoxication, clinical examinations, SOFA scores, laboratory parameters (PChE and pH), outcomes, and the duration of hospital stay were documented.
In the study, the mean age of the patients was 24.1 years (ranging from 4 to 59), with a majority being females (66%), predominantly from rural areas (52%). Intentional poisoning constituted 98% of incidents, while accidental exposure made up only 2%. The study further indicated that carbamates were implicated in 70% of the poisoning cases, with the remaining 30% involving organic phosphorus compounds. The oral route was the most common route of exposure (100%), and the time between exposure and seeking medical advice ranged from 1 to 7 hours, with an average of 2.22 ± 1.76 hours.
The study shows that the average mean arterial pressure for patients on mechanical ventilation was between 55 and 70 mmHg, with a mean of 63.54 ± 3.92 mmHg. Conversely, patients not on mechanical ventilation had an average mean arterial pressure ranging from 66 to 100 mmHg, with a mean of 88.65 ± 9.02 mmHg. There was a notable correlation between respiratory rate and the necessity for mechanical ventilation. Patients requiring mechanical ventilation had a mean respiratory rate of 29.38 breaths per minute, compared to 19.73 breaths per minute for those not needing it.
The study also noted that patients not on mechanical ventilation had a higher Glasgow Coma Scale (GCS) score, averaging 14.23 ± 1.66, while those on ventilation had a lower average score of 8.58 ± 0.88. Additionally, 91.7% of patients with a GCS score of 9 or lower required ventilatory support. Nicotinic and respiratory symptoms were more prevalent in the mechanically ventilated group than in the non-ventilated group in this study.
The mean pseudocholinesterase (PChE) level was 550 U/L in patients requiring mechanical ventilation (M.V.), compared to 1131 U/L in those not needing M.V. A significant negative correlation was observed between PChE levels and the need for M.V. Patients on M.V. had a more acidotic pH, averaging 7.26, while those not on M.V. had a normal average pH of 7.34. Out of 50 patients poisoned by acute cholinesterase inhibitors, 74% were discharged, and 26% died. The hospital stay ranged from 1 to 10 days, with an average of 3 days.
The Sequential Organ Failure Assessment (SOFA) score was higher in mechanically ventilated patients, averaging 7, compared to the non-ventilated group. A SOFA score with an area under the curve (AUC) of 0.917 and a cut-off value of >5 had a sensitivity of 79.17% and a specificity of 96.15% for predicting the need for M.V. Serum lactate, with an AUC of 0.806 and a cut-off value of ≥ 2.6 mmol/L, showed a sensitivity of 87.5% and a specificity of 73.5% for predicting M.V. need. QTc prolongation, with an AUC of 0.833 and a cut-off value of >450 msec, had a sensitivity of 83.3% and a specificity of 96.15% for predicting M.V. need. The SOFA score, particularly when combined with serum lactate levels (SOFA-LAC), with an AUC of 0.919, showed a sensitivity of 80.17% and a specificity of 97.15% in predicting the need for M.V. This suggests that serum lactate levels, QTc prolongation, and SOFA scores are reliable indicators for the need for mechanical ventilation in cases of cholinesterase inhibitor pesticide poisoning.
The predictive accuracy of the SOFA score is improved when combined with serum lactate measurements. Both SOFA-LAC scores and QTc prolongation were useful in predicting the requirement for mechanical ventilation.