한국학술정보. Clinical Investigation of Pneumonia Complicating Organophosphate Insecticide Poisoning: Is It Really Aspiration Pneumonia?

Transcription

1 Clinical Investigation of Pneumonia Complicating Organophosphate Insecticide Poisoning: Is It Really Aspiration Pneumonia? Seung Cheol Han, M.D., Young Ho Ko, M.D., Kyoung Woon Jung, M.D., Tag Heo, M.D., Yong Il Min, M.D. P u r p o s e: Pneumonia is a common complication of organophosphate poisoning and increases the incidence of respiratory failure and the duration of mechanical ventilator support. Therefore, we investigated the clinical characteristics of pneumonia as a complication of organophosphate insecticide poisoning and then determined the factors related to the development of pneumonia. M e t h o d s: A retrospective study was performed on patients with organophosphate insecticide poisoning, who were treated at our hospital with medical records and chest radiograph of patients. From January 1, 2001, to July 31, 2004, eighty five patients were included in this study. R e s u l t s: 1) Thirty-two (71% of the patients developing pneumonia) patients developed pneumonia later than 48 hours from admission and twenty-five (55.6% of the patients developing pneumonia) patients developed pneumonia later than 48 hours after mechanical ventilatory supp o r t. 2) The mean onset of pneumonia resistant to initial empirical antibiotics was 4.8 days from admission, and that of susceptible pneumonia was 3.7 days from admission ) Patients with pneumonia as a complication needed larger doses of atropine and more 2-pralidoxime injections, as well as longer mechanical ventilatory support, ICU admission, and total hospital admission. C o n c l u s i o n: Most Pneumonia in organophosphate poisoning patients were nosocomial pneumonia & ventilator-associated pneumonia. Thus, to reduce the incidence of pneumonia complication in organophosphate poisoning patients, Physicians must take measures, such as hand-washing and careful periodic drainage of tubing condensate, etc., to reduce the incidence of nosocomial pneumonia. In selecting empirical antibiotics for pneumonia complicating organophosphate poisoning patients, physicians should take regional prevalence of nosocomial pathogens into consideration. In late-onset ventilator-associated pneumonia, physicians must consider pneumonia caused by organisms resistant to commonly used empirical antibiotics. Key Words: Organophosphate intoxication, Aspiration, Ventilator associated pneumonia Department of Emergency Medicine, Chonnam National University, School of Medicine, Gwangju, Korea

2 540 /

3 541 Table 1. Comparisons of ingested drugs between the two groups Toxicity Pneumonia (+) Pneumonia (-) (45) (40) p value Low Diazinon 3 IBP 4 IBP* 2 Diazinon 2 Tebupirimfos 1 Tebupirimfos 2 Total 6 Total Moderate Fenthion 3 Chlorpyrifos 6 Chlorpyrifos 3 Edifenphos 3 Eifenphos 2 Fenitrothion 3 Dimethoate 1 Phorate 2 Phorate 1 Fenthion 2 Dimethoate 2 Trichlorfon 1 Total 100 Total High Methidathion 8 Phosphamidon 3 EPN 7 EPN 2 Dichlorvos 5 Dichlorvos 2 Phosphamidon 4 Total 240 Total Unknown 5 6 * Iprobenofos Ethyl paranitrophenyl Table 2. Time elapsed from ingestion to ED treatments Pneumonia (+) Pneumonia (-) (45) (40) p value Time elapsed to intubation (hours)* Time elapsed to gastric lavage (hours) Time elapsed to levin tube insertion (hours) Time elapsed to atropine injection (hours) Time elapsed to 2-pralidoxime infusion (hours) * pneumonia (+):pneumonia (-) = 44:21 pneumonia (+):pneumonia (-) = 43:36 pneumonia (+):pneumonia (-) = 45:34 pneumonia (+):pneumonia (-) = 44:37

4 542 / Table 3. Comparisons of treatment courses between both groups Pneumonia (+) Pneumonia (-) (45) (40) p value Dose of PAM* (g) Duration of PAM (days) <0.001 Dose of atropine (mg) <0.001 Duration of atropine (days) <0.001 Duration of intubation (days) <0.001 Duration of ventilator (days) <0.001 * 2-pralidoxime pneumonia (+):pneumonia (-) = 44:37 pneumonia (+):pneumonia (-) = 44:21 pneumonia (+):pneumonia (-) = 43:18 Fig. 1. The distribution of causative organisms with lapse of time after admission.

5 543 Fig. 2. The distribution of causative organisms with lapse of time after mechanical ventilation.

6 544 / Fig. 3. Causative organisms resistant to initial empirical antibiotic therapy in this study.

7 Shin KC, Lee KH, Park HJ, Shin CJ, Lee CK, Cheong JH. Respiratory failure due to organophosphate intoxication. J Tub & Res Dis 1999;46: Ryu HK, Han HW, Cho HY, Kim IH, Lee IS, Lee KM. Clinical investigation of respiratory failure in organophosphate intoxication. J Korean Med Assoc 1993;45: Chun BJ, Mun JM, Yoon HD, Heo T, Min YI. Clinical significance of immediate determination of plasma cholinesterase level in patients presenting with organophosphate ingestion at the time of hospitalization. J Korean Emerg Med 2002;13: Braunwald EU, Fauci AN, Kasper DE, Hauser ST, Longo DA, Jameson LA, et al. Harrison s principles of internal medicine. 16th ed. New York:Mc Graw-Hill; p Craven DE, Steger KA. Epidemiology of nosocomial pneumonia: New perspective on an old disease. Chest 1995;108: American Thoracic society. Hospital acquired pneumonia in adults: Diagnosis, assessment of severity, initial antimicrobial therapy, and preventative strategies. Am J Respir Crit Care Med 1995;153: Leu HS, Kaiser DL, Mori M. Hospital-acquired pneumonia: attributable mortality and morbidity. Am J Epidemiol 1989;129: Keenan S, Heyland D, Jacka M. Ventilator associated pneumonia. Crit Care Clin 2002;18: Fagon JY, Chastre J, Domart Y, Trouillet JL, Pierre J, Darne C, et al. Nosocomial pnaumonia in patients receiving continuous mechanical ventilation. Prospective analy- sis of 52 episodes with use of a protected specimen brush and quantitative culture techniques. Am Rev Respir Dis 1989;139: Rello J, Sa-Borges M, Correa H. Variations in etiology of ventilator-associated pneumonia around four treatment sites: Implications for antimicrobial prescribing practices. Am J Respir Crit Care Med 1999;160: Pham LH, Brun-Busson C, Legrand P. Diagnosis of nosocomial pneumonia in mechanically ventilatory patients. Comparison of a plugged telescoping cather with the protected specimen brush. Am Rev Respir Dis 1991;143:

8 546 / 12. Kelly CA, Kotre CJ, Ward C. Anatomical distribution of bronchoalveolar lavage fluid as assessed by digital subtraction radiography. Thorax 1987;42: Guerra LF, RP Bauchman. Use of bronchoalveolar lavage to diagnosis bacterial pneumonia in mechanically ventilated patients. Crit Care Med 1990;18: Mun DS, Yim CM, Bae JH, Kim MN, Jin JY, Shim TS. A study on the diagnostic effectiveness of mini-bronchoalveolar lavage to detect organism in ventilator-associated pneumonia patients with antibiotics therapy. J Tub & Res Dis 1999;47: