Snakebite coagulopathy: controversies in understanding and management

Maduwage, Kalana

doi:10.4038/sljm.v26i2.39

Cited by 7 publications

(13 citation statements)

References 11 publications

(12 reference statements)

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“…VICC is marked by prolonged clotting times, and clotting factor deficiencies (i.e. hypofibrinogenaemia, low factor V, low factor VIII) and an elevated Ddimer [2][3][4][5]. VICC has a rapid onset and resolves with neutralisation or inactivation of the toxins and synthesis of new clotting factors [3,6,7].…”

Section: Introductionmentioning

confidence: 99%

“…Hemotoxic clinical toxin syndromes carry a significant risk of haemorrhage and death. Snake venoms have toxins which can act as anti-coagulant toxins which inhibit the clotting cascade, or as pro-coagulant toxins which activate the clotting cascade and consume clotting factors [ 2 ]. The consumption coagulopathy is commonly referred to as a venom induced consumption coagulopathy (VICC).…”

Section: Introductionmentioning

confidence: 99%

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Snakebite associated thrombotic microangiopathy: a systematic review of clinical features, outcomes, and evidence for interventions including plasmapheresis

et al. 2020

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Snakebite is a neglected tropical disease with significant morbidity and mortality. Thrombotic microangiopathy (TMA) is an important but poorly understood complication of snakebite associated with acute kidney injury (AKI). Numerous treatments have been attempted based on limited evidence. We conducted a systematic review of TMA following snakebite using a pre-determined case definition of blood film red cell schistocytes or histologically diagnosed TMA. The search strategy included major electronic databases and grey literature. We present a descriptive synthesis for the outcomes of AKI, dialysis free survival (DFS), other end-organ damage, overall survival, and interventions with antivenom and therapeutic plasmapheresis (TPE). This study was prospectively registered with PROSPERO (CRD42019121436). Seventy-two studies reporting 351 cases were included, predominantly small observational studies. Heterogeneity for study selection, design, reporting and outcomes were observed. The commonest envenoming species were hump-nosed vipers (Hypnale spp.), Russell’s viper (Daboia russelii) and Australian brown snakes (Pseudechis spp.). The prevalence of TMA was at least 5.4% in proven and probable Hypnale bites, and 10–15% of Australian elapid envenomings, AKI occurred in 94% (293/312) of TMA cases, excluding case reports. The majority of cases with AKI required dialysis. Included prospective and retrospective cohort studies reporting interventions and renal outcomes showed no evidence for benefit from antivenom or TPE with respect to DFS in dialysis dependant AKI. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) assessment for quality of accumulated evidence for interventions was low. The major complication of TMA following snakebite is AKI. AKI improves in most cases. We found no evidence to support benefit from antivenom in snakebite associated TMA, but antivenom remains the standard of care for snake envenoming. There was no evidence for benefit of TPE in snakebite associated TMA, so TPE cannot be recommended. The quality of accumulated evidence was low, highlighting a need for high quality larger studies.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Snakebite associated thrombotic microangiopathy: a systematic review of clinical features, outcomes, and evidence for interventions including plasmapheresis

et al. 2020

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“…This paucity of clear evidence supporting a role for antivenom in snakebite-associated TMA is consistent with the lack of quality evidence for antivenom in the treatment of VICC itself [42,[80][81][82]. Quality control assays for research/licensing of new antivenoms and manufacturing for new batches of antivenom typically assess the neutralising efficacy of antivenoms via both in vitro and in vivo animal studies.…”

Section: Role Of Interventions: Antivenom and Tpementioning

confidence: 74%

“…); factor V/factor X activators (Daboia spp. ); thrombin like enzymes +/− other mechanisms; (Hypnale spp., Cerastes cerastes, Bitis arietans) and thrombin like enzymes/prothrombin/factor X activators (Bothrops jararaca) [7,42,43]. Of note, definite cases of TMA have not been reported in every snake species causing VICC (e.g., Calloselasma rhodostoma, Trimeresurus spp.…”

Section: Association With Envenoming By Snake Genera/species Causing Viccmentioning

confidence: 99%

Snakebite Associated Thrombotic Microangiopathy and Recommendations for Clinical Practice

Noutsos

Currie

Wijewickrama

2022

Toxins

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Snakebite is a significant and under-resourced global public health issue. Snake venoms cause a variety of potentially fatal clinical toxin syndromes, including venom-induced consumption coagulopathy (VICC) which is associated with major haemorrhage. A subset of patients with VICC develop a thrombotic microangiopathy (TMA). This article reviews recent evidence regarding snakebite-associated TMA and its epidemiology, diagnosis, outcomes, and effectiveness of interventions including antivenom and therapeutic plasma-exchange. Snakebite-associated TMA presents with microangiopathic haemolytic anaemia (evidenced by schistocytes on the blood film), thrombocytopenia in almost all cases, and a spectrum of acute kidney injury (AKI). A proportion of patients require dialysis, most survive and achieve dialysis free survival. There is no evidence that antivenom prevents TMA specifically, but early antivenom remains the mainstay of treatment for snake envenoming. There is no evidence for therapeutic plasma-exchange being effective. We propose diagnostic criteria for snakebite-associated TMA as anaemia with >1.0% schistocytes on blood film examination, together with absolute thrombocytopenia (<150 × 109/L) or a relative decrease in platelet count of >25% from baseline. Patients are at risk of long-term chronic kidney disease and long term follow up is recommended.

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“…Chappuis et al, in [16] recommended an enlightenment campaign to promote the use of protective measures against SBE in snake infested areas. Snake antivenom is considered to be the only treatment that can effectively cure or reverse the effect of snakebite envenoming, however, it may cause adverse reactions as reported in some studies [9,[17][18][19][20][21][22][23][24][25].…”

Section: Introductionmentioning

confidence: 99%

Control of snakebite envenoming: A mathematical modeling study

2021

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A mathematical model is designed to assess the impact of some interventional strategies for curtailing the burden of snakebite envenoming in a community. The model is fitted with real data set. Numerical simulations have shown that public health awareness of the susceptible individuals on snakebite preventive measures could reduce the number of envenoming and prevent deaths and disabilities in the population. The simulations further revealed that if at least fifty percent of snakebite envenoming patients receive early treatment with antivenom a substantial number of deaths will be averted. Furthermore, it is shown using optimal control that combining public health awareness and antivenom treatment averts the highest number of snakebite induced deaths and disability adjusted life years in the study area. To choose the best strategy amidst limited resources in the study area, cost effectiveness analysis in terms of incremental cost effectiveness ratio is performed. It has been established that the control efforts of combining public health awareness of the susceptible individuals and antivenom treatment for victims of snakebite envenoming is the most cost effective strategy. Approximately the sum of US$72,548 is needed to avert 117 deaths or 2,739 disability adjusted life years that are recorded within 21 months in the study area. Thus, the combination of these two control strategies is recommended.

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Snakebite coagulopathy: controversies in understanding and management

Cited by 7 publications

References 11 publications

Snakebite associated thrombotic microangiopathy: a systematic review of clinical features, outcomes, and evidence for interventions including plasmapheresis

Snakebite associated thrombotic microangiopathy: a systematic review of clinical features, outcomes, and evidence for interventions including plasmapheresis

Snakebite Associated Thrombotic Microangiopathy and Recommendations for Clinical Practice

Control of snakebite envenoming: A mathematical modeling study

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