Diagnostic 20-min whole blood clotting test in Russell's viper envenoming delays antivenom administration
Diagnostic 20-min whole blood clotting test in Russell's viper envenoming delays antivenom administration
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DOI：
10.1093/qjmed/hct102
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发表时间：
2013-10-01
影响因子：
13.3
通讯作者：
Buckley, N. A.
中科院分区：
文献类型：
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作者：
Isbister, G. K.;Maduwage, K.;Buckley, N. A.
背景：20分钟全血凝血试验(WBCT20)被广泛应用于蛇毒凝血障碍的诊断，但其在临床上的应用尚未得到评价。目的：探讨WBCT20对Russell蛇毒凝血障碍的诊断价值。设计：前瞻性观察研究。记录年龄、性别、咬合情况、临床疗效、WBCT20系列及抗蛇毒血清治疗情况。用毒液特异性酶免疫测定法确定了Russell的毒蛇毒液。我们评估了入院WBCT20对Russell蛇毒患者凝血功能紊乱的敏感性(国际标准化比率，INR>；1.5)，WBCT20阴性患者在非蛇毒患者中的特异性，并直接比较WBCT20与INR的配对。结果：140例Russell蛇咬伤患者入院WBCT20，其中56例阳性[敏感性40%(95%可信区间：32-49%)]。WBCT20阴性导致抗蛇毒血清延迟给药[WBCT20-VE试验：中位延迟1.78h(四分位数范围：0.83-3.7h)与WBCT20+Ve试验：中位延迟0.82h(IQR0.58-1.48h)；P=0.0007]。抗蛇毒血清的延迟在很大程度上是进一步进行WBCT20的结果，如果第一次检测为阴性，则更常见(41/84比12/56)。9例非毒蛇咬伤患者和48例非毒蛇咬伤患者的WBCT20检测均为阴性[特异性：100%(95%CI：94~100%)]。在与INR>；1.5配对的221项测试中，WBCT20阳性91例(41%)。结论：在临床应用中，WBCT20检测蛇毒凝血功能障碍的敏感性较低，不应凌驾于临床对抗蛇毒血清应用的评估。迫切需要开发一种简单的床边试验来检测蛇毒中的凝血障碍。
Background: The 20-min whole blood clotting test (WBCT20) is widely used for the identification of coagulopathy in snake envenoming, but its performance in practice has not been evaluated.Aim: We aimed to investigate the diagnostic utility of the WBCT20 for coagulopathy in Russell's viper envenoming.Design: Prospective observational study.Methods: Adult patients with snake envenoming were recruited. Age, sex, bite information, clinical effects, serial WBCT20 and antivenom treatment were recorded. Definite Russell's viper envenoming was confirmed with venom specific enzyme immunoassay. We assessed sensitivity of admission WBCT20 to coagulopathy (international normalized ratio, INR > 1.5) in Russell's viper envenoming, the specificity of negative WBCT20 in non-envenomed patients and directly compared paired WBCT20 and INR.Results: Admission WBCT20 was done in 140 Russell's viper bites with coagulopathy and was positive in 56/140 [sensitivity 40% (95% confidence interval (CI): 32-49%)]. A negative WBCT20 led to delayed antivenom administration [WBCT20-ve tests: median delay, 1.78 h (interquartile range (IQR): 0.83-3.7 h) vs. WBCT20 + ve tests: median delay, 0.82 h (IQR: 0.58-1.48 h); P = 0.0007]. Delays to antivenom were largely a consequence of further WBCT20 being performed and more common if the first test was negative (41/84 vs. 12/56). Initial WBCT20 was negative in 9 non-envenomed patients and 48 non-venomous snakebites [specificity: 100% (95% CI: 94-100%)]. In 221 paired tests with INR > 1.5, the WBCT20 was positive in 91(41%). The proportion of positive WBCT20 only increased slightly with higher INR.Conclusions: In clinical practice, the WBCT20 has low sensitivity for detecting coagulopathy in snake envenoming and should not over-ride clinical assessment-based decisions about antivenom administration. There is an urgent need to develop a simple bedside test for coagulopathy in snake envenoming.